26696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R IL.DING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29 C
C 6
.:¢ . :"BUILDING PROJECTIDENTIFICATION U J V
HUH DING ADDRF./S/F�/Y� I' ,5 �J•�') (� " SANITARY NO. APPLICA'HONSUBMITTALDATE
Z(f/(/ O 12"t yg� KNIT# OT#
OWNERS NA ' PHONE: CONTRACTOR'S G*X LIC NO:
�ARCHITECf/FNGIN.ER: LIC NO: AO ESS.. El ElL1 w1E'
CONTACT: PHONE: 4
QTY. ELECTRIC PERMIT FEE, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL —IOypES
Op.z Ihcrehy affirm that lamlicensed under provisiensofChapar9(commencingwith `Vr�l t.0`/C,l_.
[[100 Section 7000)of Division 3 of Ne Business and Professions Code,and my license is in PANELS
, full force Class effect.
FZW fu sc Class Lia# UP T0200 AMPS 1
m 5 are Comment, 201.1000 AMPS S IT.FLOOR AREA $ISQ.FT.
Fy ARCHITECTS DECLARATION OVER 1000 AMPS
Q
ZO b.N❑ I understand my plane,hull he used ax public recoN,.
F,y F E SIGNS ELECTRACAL
5�-- Licensed Professional
yy OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISE.
O y V I hereby affirm that I am exempt from the Contractor's License Law for the
W'3OvF-i fallowing reason.(Seminn]031.3.Business and Profession,Code:Any city or county TEMP.METER OR POLE INST. �1 r\P,
so which requires a permit to construct,alter,improve,demolish,or repair any improve it Ifl /p
2,i• g m its issuance,also re the applicant forsnch Go file a signed statement POWER DEVICES
K❑ prior quires pp permit gn
�'p0 @athelsrilicensed withsuummtheproviNhi 3.fma Bunm's License Low(Chapter 1
m 9(wmmendn NSwdon]000 of Division3of the Business and Profasslons Coda SWIMMING POOL BI,ECTRIC .o
Oµ, (concerning ) ) ; A TION
' gym or that Sectioheisexampt byway therefrom and thepermit subjeasegedexemptt to civiny l olation
of OUTLETS-SWITCHES-FIXTURES 6[/
Sat are 03m by hundred
delt,,($50rmi[subJeds the applicant to civil ponalry of
0 not more than five hundred dollars(&300). NEW RESIDENTIAL ELECTR
W�m ❑ othewrk,an thestrerty,ormyemtendeeswiowed for Neireole n44,Business —__ _ PE CONSTRUCTION
0. Lact FT
will do Newons and Code: he Coutisnor's Lic ese La does nota(ply to an Business
and Professions lds mThe Contmcmrs License Law does not apply to an owner of
own
property who builds or improves thereon,and who does such work himself or through his
Cmploycee,provided that suchimprnvements arenotimendedorufferedforsule.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within oneyearofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
g❑) d
I ro
as ownerofthe ppertyam exclusive) QTY 1 } PLUMBING PERMIT- r i,,e FEE; FLOOD ZONE APN
ycontrnotin gsrith licensed contractors to arae al't,.
License the protect(Seo.]044,Business and Professions micil The Contractors -h
whocotract does not pplyto jects with acontpropertywhosed pursumproves thereon.and PERMIT ISSUANCE
whocontractsLoss
forauch projects with acomracmr(s)licensed pursuant mthe Conradnr's
Llwn,e Luw. ALTER-DRAINffi VEN'P-WATER(G) ,PGE SUMMARY - -
❑ I am exempt under Sec. ,B ffi P C for this reason BACK FLOW PROTECT,DEVICE " T 1 E FEES
SANITARY Y N
Owner Date RECEIPTN
DRAINS-FLOOR,ROOF, COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihcreby aHlrm that lhave v cenificemof consenuo self-Insure,orawABcare ofFIXTURES-PERTHAT RECEIPT#
Woders'Campensatlon lnsurenw ore certified copy thereof($w.3gW,Lab CJ which PARK FEE. Y N
covers all employee's under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE -
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE MAP SOILS FEE
COMPENSATION INSURANCE
('"k,acdonmwdnat beoompleted iftheperund is[Drone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
orles,.)
I Certify that in the parfnrnanceofthe work for which this permit is issued,)shall WATER HEATER W/VENT/ELECTR
not employ any person in any come,so as to become subject no the Workers' �a'4 PAID
Compensation Laws of Califmmia. Date A17RSY .M/TRFATING V Date Receipt#
O Z Applicant
Z NOTICE TO APPLICANT:IL after making this Canifeemof Exemption,you should BSIDENTIAL PLMB. SQ.FT. TOTAL:
Pf/] become subject m the Worker's Compensation provisions of the Labor Code,you must
P forthwith comply with such provisions or this permit shrill be devoted revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
C✓ I hereby affirm that th re...nstructlem lendingagency for the perfnrnanw F ELECTRIC PEP.
thew k f blah this pe t is pyre 301 Cis.C.) -
,r Lender',N e - "
Lend Address QTY(;'y f MECHANICAL PERMIT; C"FEES 4 PLUMBING FEE
Q U I rectify that I have read this application and state that the above informations s t
W
correct.Iagree to comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICAL FEB
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify keep ha ess the City of Cupertino against
liabilities,judgroents,were shrtw any way aecmcagalnet said City AIR HANDLING UNIT(TO IO,WO CPM)
nsequenc gran' Nis pemt
AIR HANDLING UNIT(OVER 10,000 CFM)
Signatureof ApplicanUContnmtor Dam EXHAUST HOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Swticn 25532(a)1
11 Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCFDATE
Will air contaminants
s defining by The Bay Area enmuality esanagemech nt p A ,
hazardous air conmminants os defined by the Bay,Area Air Quality Management BOILER-COMP(OVER 100,1100 BTU) N
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 1t m 7 1994
I have read the Incautious materials requirements under Chapter 6.95 of the JUL
California Heahh ffi Safety Code,Sections 25505,25533 and 25534. I understand that 1 k
if the building does not currently have a tenant,that it is my responsibility to notify the (;tyy Ur Vurri!
wupom of the requirements which must be met prior m issuance of a Pembina of V 1
wner Occupancy.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE