26476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1 .- .L I A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMflING-MECHANICAL 2 6 4 7 61'
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPIJCATIONSUBMITTALDATE
6 DD
J ✓3/t 'IW Cn� WIT# LOT#
S AME: PIIONE: C ACTOR'S NAME: LIC NO:
NIC CONTROL#
5 R.HITECfIENGINEER: LC R
SIW91'71
-.NTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ci ❑ ❑
LICENSEDCONTRACTORS
ONT ACTORSDECLARAT
ION APPLIANCES-R
ESIDENTIAL
pCZ Ihertby affirm licensed under
via9(commencing with JOB DFSC^R
ON
Seco )Of Division] fthe Business and Professions Cede,and my license is in PANELS
at& full force and /�- 5fmi�
Ny 57 9.!/3 UPT0200AMPS
=y
ate Contactor 201-IIXO AMPS/
Z m ARCHITHCTS DECLARATION OVER 1000 AM 5 SQ .FLOOR AREA S/SQ.FT.
O Z
—Q 1 understand my pleas shml be used as publi<rtcoNs.
F y ; SIGNS ELECTRICAL
Licensed Professional p1
Woe< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M t YM1••li
O y U I hereby affirm that I am exempt from the Contractor's License Low for the
00'3 ti�0 m following reason(Section 7031.5,Business and Profewhim Cade:Any city or county TEMP.METER 0.PoLE S f
f='LL ON; which requires a permit to construct,alcor,improve,demolish,or repair any structum
EN}� prior m its issuance,into requtrn Nemplicaut forsuch permit to file a signed statement POWER DEVIC
4OC thin he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(cammrncimg with Section')0M)m Division 3of the Business and Profesions Cale) SWIMMING POOL ELECTRIC VALUATION
,pp--Mo, oMat he is exempt asrefrom and We basis far thaallegW exemption.Any violation of / I ��O
�Q Section 7031.5 6y any applicanl for a pernit subjects the applicant m a civil penalty of OUTLETS-SWITCHES-FIXTURES lel'.
SS� not morethan five hundred dollars(SSW). NEW RESIDF.NTIAI.ELE SQ.FT.
Fm ❑ I.mownerofthepropeny,ormyemployeeswiNwaguastheirsolecompensati.,, STORIES TYPECONSTRUCTION
y�3_ will do the work,anathestionture is not intendedoroffered foraale(See 7044,Business
and Professions Code:The Commetors License Luw does not apply to an owner of
property%whirildsarimproon therean,and whodoessuchworkhimselforthmugh his OCC.GROUP ICES.UNITS
awn employee,provided thmsuchimprovements arcnotintendeJoroffertdforsele.If,
however,the building or improvement is sold within one year ofcompletion,the owner- TAL:
buihler will have the burden of proving that he did not build or improve for purlrae of
sale.).
C] 1,u ovocrofthe property,am exclusivelyconuacting with licensedcoammum to QTY. PLUMBING PER FEE FT.00D ZONP. APN
/cmubnmu tire mi(Sec.7044.Bnsiness and Professions Code:)The Contromm'.
a License Law does not apply to on ownerofperperty who builds or improves thereon,and PERMIT ISSUANCE
whoamtracts for such projects with acomroctur(0 licensed puruant in the Camtrecmra
License law. ALTER FEA)> FEESUMMARY
❑ I am exempt under Scc. ,B&P C fm this reason BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
SANITARY Y N
6G.""'Iturclay.ffironflum
Date DRAINS-FLOORROOF, GONDRECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
l have.emificareofcomenuo self.faux,m.certificate of Fl%TURES-PER TRAP RECEIFF#
orkerx'Compcasmion Insurance me certified copy therrnf(Sec.3800,Lab C.)which PARK IEE Y N
covers all employee's under this permit. RECEIPT'#
GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTII-OVER 4(LA) PLANCHEIK FEE
❑ Certified copy is heuby fumished.
❑ Certified copy is fided with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2001"T. ENERGY FEE
or loss.)
I cenifyth.t in the if...of the work for whichthis pemdt is issued,.shall WATER HEATER W/VENT/HLECIR
not employ any peason in any marmer so n to become subject to the Workers PAID
Compensation Lawsof Califomis. Date WATER SYSTEM/TREATING Data Receipt#
O z Applicant
z Q NOTICE TO APPLICANT:IL after making this Cenifieme of Exemption,youshould NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
ybecame subject o the Woskels Compensation provisions of the Labor Code,you must
ai 7 forthwith comply with such provisions m this permit shml be deemed revoked. BUILDING FEE �#
a QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
iU- z work
mfrs Net Vert is asued(Sec.3097,on Civ agency for the performance of
L) O the work for which this parotin is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name
R. QT,1=: -;,MECHANICAL PERMIT FEE PLUMBING FIX
-
I�+ Izda I c A fy that
LU I certify that 1 have red this application and state that the shove information refs ing to MECHANICAL FEE
0. ilea.lagrcemcomply withall cityyam and county ordinances osand stateto enter
gto PERMIT ISSUANCE.
L47)
building canstroctian.and hereby auNoriu representatives of this citymenter upon the - CONSTRUCTION TAX
ahuve-mentioned propedy for inspection purposes. ALTER OR ADD TO NIECE,
(Wc)agree to save.indemnify and keep harmless the City of Cupertino against
liabilitis.judgmenta.corn and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,0001 CFM)
in con. uence of the granting of permit.
AIR HANDLING UNIT(OVER 10,000CM)
'rLgj:!5VFofApplicmVComractor Dam EXHAUST HOOD(W/DUCT) PAID
If RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant at future building occupant store or handle hereabouts material
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,030 BTIO TOTAL:
Code.Section 25532(x)? VENTILATION FAN(SINGLE RESID) \
❑Yes ❑No
BOR.F.R-COMP(JHP OR 100,000 BTU) ISSUANCEDATE
Will Neopplicutorfutmebuildingaccupantuseequipm ntmdevimswhichemit P
htowdom mi
air contaminants as defined by the Bay Aren Air Quality Management BOILER-COMP(OVER IW.WD BTU) P410
p
❑Yes ❑Nor/t'
NEW RESIDENTIAL MECH.—SQ.Ff.
1 have..it the hiumidous materials repurememrs under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 add 25534. I understand then y/7�
ifthe building does not currently have a among.that is is my responsibility to notify the
occupant of the requirements which must be met prim to issuance of a Cenificme of h LL~rh/
Occupancy. 'I
Owner or authariaW agent Date TOTAL: ISSUED BY:
OFFICE