26380 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
HIM LA G-KLKUI RICAI. PERMITNO.
APPLICATION/PERMIT PING,PROJECT IDHANICAL
FICA 2 6 Q Q O
OUILDIN(.DIVISION BUILDING PROJECT IDF.NI'IFICA'f1ON L Jo
.Ula OES^g: / L^ SANITARY 0. APPLICA91'IONSUI IITALDATE
�1./,\� UNIT# LOT# I� ICT
OW ERS NAME: PHONE: CONTRACTOR'S NAME IC NO: N/C CONTROL;
SI�� S►' U- b
ARCHITECT/ENGINEER: LIC NO: q DRESS: k ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FFiE
UG hl, ECT PLUMB MECII
PERMIT ISSUANCE lj�y/\�N'
LICENSEDCONTRACTOR'Sionsof upter!AJ N gppLIANCFS-RPSIDENTIAL TOB DE N ON
Oy�Z IherehyaffirLICENSE liCONTILACTOR'SD CLAxRmpmr9(commencing with
4100 Section 7")of Division 3 mf the Business and Profusions Code,end my license is in PANELS
tK 41 full force and effect. ssr
('Z License Class Lia# UP TO 200 AMPS
m8-<ec Data Cimarron 201-IOW AMPS
ZOyZARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ_O Iunderstandmy ims,hull he used as publicrecords.
F y C tv SIGNS ELECTRICAL
6 � Licensed lhnfe,sinnal
C OWNER-BUILDER DECLARATION SPECIAL CIRCUIOMISC.
KOaF I hereby affirm that I am exempt from the Contractor's License Law for the
4131x.
0ran following maxon(Section 7031.5,Rosiness and Professions Code:Any city or county TEMP.METER OR POLIi INST.
1"'a ec.] which requires.permit to canstmct,elrtm improve,demolish,or repair any structure
W}� prlarm its issuance,also require,the applicant for such permit to file a signed andmet POWER DEVICES
4100z that he is licensed pursuanrto the Provisions ofihe Contractor's License Law(Chapter
t1goW 9(commencingwith SectionOWO)of Division3ofthe BusinusmdProfessions Code) SWIMMING POOLELECfRIC VALUATION
'iWZm nonion7 sexemptayri pli and the basis fonhc alleged exemption.Any violation of
F_Za Section 903 L5 by any applicant fora permit subjects the applicannoecivil penalty of OUTLETS-SWITCHES-FIXTURES
nm mare than five hundred dollars($500).
COp W RESIDENTIAL _SQ. f.❑ NE
STORIIS TYPE CONSTRUCTION
a 3=° will dome,im.Codec he Contractor's
Lic iii,Law
not apply to an owner
of
and Professions Cade The sthma License Lew des not apply In an owner of
pnspemy who builds or impmvo thereon,and who does such work himself or through bis
ownhowemployebuildividedthatsuchlmproveme thin not earoedmoffercd reminds.If,
OCC GROUP kIS.UNI'T'S
however,the
avet a orimprovementissold edidnone yam ofmproe for purpose f TOTAL:
builder will have the harden of proving that he did not build or improve for purpose of
le.).
❑ 1,mnwneroilhepmperty,amexclusively contracting with licensed contrudorslo QTY. PLUMBINGPERMITPIiE. I1.O0D ZONF. APN
cmutmet the project(Sec.7(004,Business and Professions Code0'Ibe Commctia's — PERMITISSUANCE License Law does not apply to tom
n ownerofppeny who builds or Improves thercm said
who contracts fmsuch projects with aconbactor(e)Iie Itemized pursuant to the Contmcers AMAMI
V
License Law. IFA) FEE SUMMARY
❑ lam exempt under Sec. ,13&PC for this reason IITSID: .E.
SANITARY Y_N
Owner Dae P RECF.IPTp
WORKMAN COMPENSATION DECLARA3'IONOL TAX Y_N
C3 hereby affirminterment that l have a emificam ofcomeno self-insure,or a certificate of RECEIPT#
Wmkers'Compensatma Insurance or a certified copy mereof(Sec.3800,Lab C.)which PARK HE Y N
covers a 11 Cmploycei under this permit. S 1 4O6TLEl'S RECEIPT
Policy# BUILDING DIVISION FEES
Company -OVA 4vie PLANCIIECK FEE
❑ Cemifiedcmpyisherebyfumished.
❑ Certified copy is0 en with docrity lmapectiondivision. p WA PTOR GRADING PCF:
CERTIFICATE OF EXP.MPfION FROM WORKERS' GREASIss"ll"IF Will
SOILS FEE
COMPFNSATION INSURANCE
(This sectionneednot be completed ifflepermit I.forces handreddollan($ME ER-S ENERGY IEE
mess.)
I certify that in the perfarmatce ofthe work forwhich this lam b,is issued,Imall WATER IIEATHRW/VENT/H
not employ any person in any ma at m become subject to the Workers' 41 PAID
Z Compeasation Lawsof California. Date so IWETREATING Dae Receipt#
Applicant
C NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NBW RFSIDENTIALP B. SQ,Ff. TOTAL:
v) hecomesubject to the Worker's Compensation provisions oflhe Labor Code,you must
? forthwith comply with such provisions or this permit shall be deemed!revoked. BUILDING FEE
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
VZ I hereby affirm that then is a construction lending agency for the performance of
O the work for which this permit is issued(See,3097,Civ.C.) TOTAL: ELECTRIC FEE
Lendsex Name
C) F Lenders Address QTY. MSCI IANICAL P13RMIT IT PLUMBING FEE
V 1 certify that I have read this application end swat that the above infam od an is
mnect. lagreetocomplywithullcityandcoumyorJimmcaandstateiuwsrelatingm PERMTf ISSUANCE MECHANICAL FEE
F's buildiagconstmetion,and hereby authorize representatives ofthis city to enter upon live CONSTRUCTIONTAX
U 7 ohne-memioncd property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
piubilities,judgnnents,cnswcodexpenus wNch may in any way ac ru<ugun. said City AIR HANDLINGUND(TO I(I,Pgp CFM)
in encu
fill geed If of this permit. /
(C_ AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Conmm I e EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE I(EATING UNIT(TO 100,000 BTU) Date Rcceipt0
Will the...Ileant or future budding sneer store or handle hamidous maeriul III3ATIN0 UNIT(OVlelt I W,tgq BTU) TO"fAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553200
Cl Yes El No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100000 BTU) ISSUANCE DATE
Wilhhenpplicant nrfuwm building occupantmeequipmenmrAcvicee whichemit , ppSS �S
baurdous air comwmimamw as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Ifs A 9 D
District?
❑Vex ❑No NEW RESIDEN9'IAL MECH.-SQ.FI'. 'S
I have read the hazadon.s materials requirements under Chapter 6.95 of the MAY 1 6 1994
California Ifealth&Safety Code.Sections 25505,25533 and 25534. 1 understand that a�a7
I
the building does not currently have a tenam,that it is my responsibility to amity the CITY Ut-
He pasn of the requirements which must be mm prior to issuance of a Ccni0cme of V Y V �V
Occupancy. jzp
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE