26496 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD( x-EL CTRICAL PERMIT NO.
BUILDING 1XVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26496
BUILDING PROJECT IDENTIFICATION
BUILDING ADORES SANITARY NO. �APFLICATIONSUBMIITALDATE
UNITN LOTH
O ERS N4ME �I� n S� PY CO T�PYSI-jfs�.lE: 1( LIC NO: N/C CONTROL#
VV Yy-!i , 1`{a,, 1 -. W. 331zIJ
CCHITBCT/ENGINEER: LIC NO: Ap SS' ,
5;A Asa 5'W ❑
CONTACT: PHONE: BUILDING PERMIT INFO
.�KJK5 33 5 e Qu QTY. ELECTRIC PERMIT FEE
fR/vlRa BL� 4LEg PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
qzZ (hereby offind that l am licensed underprovisioneof Clepter9(commencing with
f40
0 Section 7000)of Division 3 of the Business aProfessions fessions Cade,end my license is is t PANELS
• Fy V full force and effect. /�
y
.zW License Class Lic.N UP TO 200 AMPS '� � )
ry
rn 6 Data Contractor 201-1000 AMPS �A
ARCHITECTS DECLARATION OVER 10!10 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
20v to
OXG IundersWnd my plans shall be used as public records.
O�
SIGNS ELECTRICAL
g Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°JOyF I hereby affirm that I em exempt from the Convectors License Lew for the
following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
o, which requiros a permit m construct,alter,improve,demolish,or repair any stmaure
prior to its issuance,alsorequires the applicant for such permit to file a signed statement POWER DEVICES
OO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
L C 9(commencin with Section]000 !Division 3ofthe Business and Professions Code SWIMMING POOL ELECTRIC
cdoB, (commencing )d ) VALUATION
{
cd!2w q,hot M1eisexempt therefrom and the bamailauthe alleged exemption.Any violation of UTLETS-SWITCHES-
�Z,Y action the.5 by hundred
dollrs($permit subjects the applicannoeCivil penalty of FI%TURES �C//w
O t9m more than five hundred dollars($Sfm l Le
NEW RESIDENTIAL ELECTR _SQ.FT.
Cm ❑ I,asownerofthepmperty,ormy employeeswi0 wagesas theirsolecompensomm, STORIES TYPECONSTRUCTION
y will derhe work,and the structure is not imendedoroffared for sale(Sec.7044,Business
and Professions Code:The Connectors License Law does not apply 0 an owner of
property whobuilds arimproves Blared,and whodoes such workhimselforthrough his
dad fiat suchim OCC.GROUP RES.UNITS
howemNayees,provi provementhin neyoundedoroffered the owner-
builder If,
however,the building ur improvement Va sold within oneyear of completion,the ae.). will have the burden of proving that he did out build or improve for purpose of
s1 QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ 1,as owneroRd(Sec rty,1. xcnesivelad Professions
with licensedtContr Contractors
ts to ors
!
consumer the pmjen(gee.7040.Business and ywhobione Cade)The Contractor's 1
License Lawdoesnot apply to uchfajects oh aconpropenywhosedplds orimproves Cormacand PERMIT ISSUANCE -
wicense ractsforeuchprojeas with econnacmr(s)licensed pursuanuo the Contmetore ALTER EA
License Lew. ( ) FEE SUMMARY
❑ I em exempt under Sec. B at P C for his reason BACK FLOW PROTECT.DEVICE SANITARY DUTY N
Owner Data OWNS-FLOOR,ROOF,AREA,COND. RECEIPT is
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
1 Q I hereby affirm that l have a cenlfiwte ofcoment be self-insure,ora certificate ofFIXTURES-PER TRAP j CEIPTla
.Workers'Compareation insurance or a certified copy thereof(Sw.3800,Lab C.)which PARK FEE N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS �� IN E1PTis
Policy N BUI ISION EBBS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKF
❑ Certified copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASEANWSTRL WASTE INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTIO 0 ORKERS' GREASETRAP S
COMPE SATION INS
(This section need notb,cam ledif a nehundreddollars($100) SEWER-SANITARY-STORM EA.200FT. EN G
orles,)
letiifythatiathe perfotmp r forwhichthisper hi iya d,lshall WATER HEATER W/VENT/ELECTR
not employ any person in any der so ar rn-b ccon the YorkersPAID
Compensation Laws of Cshe in re WATER SYSTEM/TREATING Date weiplN
O z Applicant
z 0 NOTICE TO APPLICANT:If,aftertililding this Certificate of Exemption,you should NEW RESIDENTIAL PLMIU SQ.10. OTAL:
to become subject to the Workers Compensation provisions of the Labor Code,you must
� ; fonhoom comply with such provisions or this permit shall be deemed revoke. BUILDING FEE D
I W z affirm. CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
^a I hereby arm thatthem is a construction lending agency for the performance of
U0 We work for whish this permit is issued(Sec.3097,Civ.CJ A ELECTRIC FEE
ti
Lender's Name
PLUMBING FEE
Partners' Address Q7T. MECHANICAL PERMIT FEE r'
V I certify that I have read this application and sure that the above information is byz
>" W 'eorem.I agree m comply with all city and county ordinances and stare laws radial 6 to PERMIT ISSUANCE. MECHANICAL.FEE r
)e adding construction.and hereby appear m representativesofthis city to enter upon the
ISL r V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL /s CONSTRUCTION TAX
ri
(WeLlIll to save,indemnify f keep h�rtBless the City of Cupertino against
liab"1 ns,costs andexp swhicl fay in any way accrueagainslsaid City AIR HANDLING UNIT(TO 10,000 CFM)
co nceu rhegmntin o is Dattel / AIR HANDLING UNIT(OVER 10,000 CFM)
I)
gnamraof Applicant/Connecmr Dae EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) �, Date Receipt It
Will the applicant or future building wcupmt store or handle Institutions material
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health add Safety HEATING UNIT(OVER 108000 BTU) TAL:
Coda,Section 25532(a)7 VENTILATION PAN(SINGLERESID)
11 Yes ❑No
Will @eapplicant orfuturebuilding wwpentuseaquipmcntordeviceswhichanit
BOILER-COMP(SHP OR 100,00)BTU)Will
DATE
",sanctions air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,!100 BTU)
burial] p A p D
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the NOV 1 190A
California Health&Safety Code,Sections 25505.25533 and 25534. Iundereandfiat �tl �V/ 1 Jug
if the building does not currently have a tenant,that it is my responsibility in notify the
accupam of the requirements which must be met prior to issuance of a Certificate of
Occupancy. Cify Ur vur Dvu
Owneroramhorisedagent Date A ISSUEDBY:
' OFFICE