26552 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC I RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL /� 8�
BUILDING DIVISION BUILDING PROJECT IDENTIFICA'T'ION 26552 L
BUILDING ADDRESS: I I SANITARY NO. APPLICATI/ON'SUBMI'ITALDATE
114 4 �/1 "I�� Ko UNITY LOT# rI 1�
OW RSNA ,1 PHONE: Q C CO CTOR'S NAME: OgCLI
OW
VA TS 7 .ryQS v J e op
O�f r*SZ N/C CONTROLq
CIIITyCT/ENGINEER:Ga OHMS LIG/ `� b A1'zs Q O� A✓e r,�l tt El
CONTACT: PHONE: QTY, " ELECTRICPERMIT FEE BUILDING PERMI'P INFO
Q J 1 Q B�G L•I.F.CJ' � MECII
^� �L�� I�' Q/��� PERMIT ISSUANCE
IY_(A, ❑
LICENSED CONTRACTOR'S DECLARATION pppLIANCPS-RESIDENTIAL TOB DESCRIPTION
p R;Z I hereby affirm that l an licensed underprovisionso Chapter9(cammencing with
pi100 Section VOW)af Division 3,,Qhe Business and Professions Codd,and my license is in PANELS
CU full forte and efscle ill /� YO JLfZW LicenImm UP T0200AMPS
N7y Date C.ntramr ILS 201-Ig1U AMPS
8mZ ARCHITECT"S DECK TI r
OVER IWO AMPS -• Q�FI'.FI: ORA I: $/SQ.IT.
O ❑Zlu craw mylAmashallbeuscdaspublic rtc.r
QN[— SIGNS ELECTRICAL 1Y�
$.,.I Licensed Professional
EOWNER-BUILDER DECLARATION SPECIALCIRCUI'1'/MISC.
KOiU 1 hereby affirm that I ma exempt from the Contractor's License Law for the
W LL O sFn following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which rcyuires a permit m consvuct,alter,improve,demolish,or mpair any suucmne
WYE prior to its issuance,also requires the applicant l'or.such Pemlh 10 file asigneJ swmmcn[ POWHR DEVICES
W C C pz that he is licensed pursuant to the provisions of the Cannot LicenseIxw IChapmreye
dkoLL 9(commencing with Section70BEm'Division 3 offle Business and Par4 ons Cude) SWIMMING POOL ELECTRIC / VALUATION
Wy 2radial he is exempt therefrom unit the basis for the alleged exemption.Any violation of QUTLETS-SWI'1'CI{ES-Pl%TURES C
IZQ Sec[inn](IJLS by wy applicum fora permit suhjecw the epplicunuoucivil penalty of
nor mom than five hundred dollars($500).
�Cce ❑ 1,asownerofthepTo any,ormyemploymswithwagesmtheirsoleco.p,n'.tion, NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUC ION
63�e will do the work,and the sanctum isnot inteadedorel bared for sale(Sec. Business _
and Prolbasions Code:The Contractor's License Law does not apply to an owner of
propertywhobuildsorimprovesdmemon,andwhodmssuchwod Nmselfnnhmughhia OCC GROUP WiS.UNITS
ownemployees,provided that such improvements am maintendedo,offend fortale.If,
however,the building or improvement N sold within one year of completion,the owner-
builder will have the burden of proving[hut he did not build or improve for purpose of
sale.).
CI Las owner of[he Oratory,amexclusively contracting with licensed rintmctom t. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consvuct the project(Sec.7054,Business and Professions Code)The Conoatior's
License Lawdol apply to..ocaner.fpepeny who builds.,improves thereon,and PERMIT ISSUANCE
who convects for such projects with a c.mmutor(s)licensed pursuant to the Contractor's
License Law. AL'IUR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ Tam exempt under Sec. ,B&PC for this reason BACK MOW PROTECT.DEVICE SANITARY O Y E L---N
CE
Owner Date GRAINS-FLOORROOF,AREA,GONDBEIPI'It
, . , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y—N—
I hereb
Ihereby affirm[hat l have x certificate ofc.nss tto self-insure,or a cmrifiare of FIXTURES-PER TRAP RECEIP #
Workers Compensation Issurance.recertified ropy thermf(Sce.3800,Lab C.)which PARK HE Y N
n all employees undenhis permit. RECEIPT il
Policy# GAS-EA.SYSTEM-1 INC.4 OUTLET'S BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(13A) PLANCIIECK FCC
kQ Gerified copy is herehy famished.
Certified copy is fled with the city i nxpecti Division. GRBASUINDUS'IRE,WASIE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FUSE
COMPENSATION INSURANCE
GLOM section need not be completed ifthe permit is for one hundred dollam l$100) SEWER-SANITARY-ST ORM EA.20017. ENERGY HE
ar less.)
I certify dmt in the performance of the work fur which Nis permit is issued,Is hall WATER HEATER W/VENT/HLECTR
oat employ person m any manner so as to become subject to the Workers' PAID
z Compensnri xnf Califomia. Date WATER SYSTERVfRG'1'ING Data RemiptM
Applies t
OZQ NOTICE P CANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIALPLMB. SQ.R. TOTAL:
F" � becomes,,'re he Worker's Comtennmion Emekinow f the Lobar Code,you ma,,
7 forthwith comply with such provisions or this permit shall be rimmed revoked. BUILDING FEE
�
j W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
R✓✓ I Ii.mbyaflirm that hc ...buctom lending agency for the performance of
V O the work for which thw ed(Sec.300],Civ.C.) ELECTRIC FEE �e
Lender's Name
V. U Lender's Addmxx u QTY, /') i MECHANICAL PERMIT• FEE PLUMBING FE[!
IJ Vj 1 certify that 1 have read this application and state that the above information is MECHANICAL FIE
7>1
F CL coma. I agree to comply with all city and county ordinanma and swat laws relating to PERMIT ISSUANCE
huildiii,wascdoand hereby uniform mpmm m
rescatives ofrhis ciryenrupnnrhe CONSTRUCTION'TAX
V z wmamwe-me n oned p ny far inspection purpose'. ALTER OR AUDIO MECII.
.. e)eg ,indemnify and keep harmless the City of C penin.a inst
lis 1 ,judgn nno
n, ocince a e an dcxpensuwhichmoyinanywayaarve geinstsai City AIR DANDLING UNIT(TO 10.00)CFM)
gmn'ng of this lentil, AIR DANDLING UNIT(OVER I O,OW CFM)
wm
. of Applic no Tactor 6 amT EXHAUST HOLD(W/DUCT) PAID
IIA DOGS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicard r future building Occupant store or handle hmsrdous material
m defined by rhoi ire Municipal Code,Chapter 9.12,and the Health end Safety BEATING UNIT(OVER 100,000 BTU) TOl'
Code,Section 25532(u) VHNT'ILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will rheapplicen[or faterebudding acuparimseequipment ordeviceswhich emit BOILER-COME QUP OR IBgOCO BTU)
mnrdons air contaminants as defined by the Buy Area Air Quality Management BOILER-COME(OVER IW.00J BE
�If
9isvia9
❑Ye' 11 No NEW RESIDENT JAI,MECH. SQ.IT. P ,4
n .r 1
I have read the formal materials requirements under Chapter 6.95 of the t!� (,fa
California l lealth&Safety Code cdions 25505.25533 and 25534.I understood that ��� �
if the building does not con y a s tenni,rhe[n is my responsibility rif rhe ���
mutmn of a •quimme is mail be mer Friar to i.... f ef[Ilic of Q /VLA
Occupancy CIS
Owner ora oriard agent m TOTAL: ISSUEDBY: - t
OFFICE