26562 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO 1 tL -EL R AI. PERMIT NO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
CTIDENNIFICA 26562
BUILDING PROJECT IDENI'IFlf.A'TION
BUILDING ADDRESS: / SANITARY NO. APPLICATIONSUBMIITALDATE
1 C UNIT# LOT#
WNERSN ME: PHONE: CONTRACT 'S E: LIC NO: �•:!
cdt- el& f61,ln W dG NIC CONTROL#
. ARCHITECT/ENGINEER: LIC NO: A DTR%SS: Elf
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
(S - / PERMIT ISSUANCE BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I APPLIANCES-RESIDENTIAL LOB DESCRIPTION
py.Z Ih700 affirm Division tort 3,dh Bussed iness
rnd Pronsions Code.a co mmencing wih � �
{x100❑ Section]000)of Division 3 of the Business and Profeuion Code,and my liceme is in PANELS
W full force and effcet.
<ZZ Liems Class
- LIC
,# UP TO 200 AMPS
vFi<y
Due GU201-1(x30 AMPS
ZOy� ARCIII'TECTT'SD DE LARATION OVER IOW AMPS SQ.P.FLOOR AREA � $ISQ.FT.
O Z^ I underuand my plans shall M used as Public records.
r^ W SIGNS ELECTRICAL
yy � Licensed Pmfeasional
WKC< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
EdxOiU I hereby affirm has I am exempt from the Comtrncmrs License Law far he
FLL U.in following.... SaGon]031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
05 asO /
which requires a permit to construct,after,improve,demolish,or repair any strucWRE
�tN� pdorto its iswance,alsorequires the applicant for such Permit to file a signed statement POWER DEVICES t, x
tax <p that he is licensed pursuant to he provisions of the Contractors License Law(Chapter
e. 0 9(commencing with Section 7")of Division 3 ofhe Business and Professions Code) SWIMMING POOL ELECTRIC \ > N
—y or that he is exempt herefrom and the basis for the alleged exemption.Any viohtimcd a
Y Seaion]01156y any applicom fore permit subjects the applicannoncivil penalty of OUTLETS-SWITCHES-FIXTURES I1 vL Y
onot more than five hundred dollars(8500).
propery,ormyemployceswithwaguastheirsolecompemsation, NEWRESIDFNTIALELECB _S FT.
❑ Lasownermflhe t CONSTRUCTION
W ao will du the work,andthe stmemu isnm immuadesimufferedforsile(S..]044,Business
and PmPossims Code:The Comraaors License Law does not apply m an owner of
propmy whobuildsorimpmveahereon,mdwhodoeswchwmk himselfmthmughhis OCC.GROUP EAIN
employees,pmv ided that such improvements are not imended m offered formic.If.
however,the buildingorimpmvemeni is sold within one yearofcompletion.theowner- TOTAL:
builder will have he burden of proving that he did not build or improve for purpose of
le.).
❑ I,asowneroftbeMNny.amexclusivelyconuwtingwithlicenudconrc tonm QTY. PLUMBING PERMIT FEE FLOOD ZONE
construct he Project(Sec.7044,Business and Professions Code:)The Comracmra PERMIT ISSUANCE
License Low does not apply m an ow n er of property w ho bu ilds or improves thereon,and
who contracts orsuch famous with acnmrucmr(s)licenxrm
d pursuant ContraContractor'scr's
Licensese Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B ffi P C for his meson BACK FLOW PROTECT.DEVICE SANITARY OUTYIOE fE N
0Q Dart DRAINS-FLOOR,ROOF.AREA.COND. RF.CF.IPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
0IhereM1y affirm Jutlhaveecenificeu ofcanentmulf-insurt.oraanificaas of Fl%-TURFS-PER TRAP RECEIPTN
n
Workers Compeedon Insurance or a terrified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
coves all employee' undPChts t. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy ��+#O✓G1-9; BUILDING DIVISION FEES
CompGAS-EA.SYSTEM-OVER 4 CA) PLANC14ECK FEE
❑ Cenifsedcopyisherebyfumished.
❑ Certified copy is fled with the airy inspection division. GREASPONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
Gbissedoo need not be compleed ifhe permit is forum,hundred dollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
orless.)
I cenilYthm in he performs.,fthe work forwhich this permit is issued,)shall WATER HEATER W/VENTIELECIR
not employ any pc.in any manner to u to become wbjcet m the Workers PAID
Cumpemmiom Lzwsof California. Dote WATERSYSTEMIMPATING Date Receipt
O Z Applicant
0 NOTICE TO APPLICANT If,after making this Cmificate of Exemption,you should NEW RESIDENTIAL PLAUL—SQ,Fr. TOTAL:
. become h mo the Worker's Compensation provisions of the Labor Code,you must
a forthwith
hwith comply with such provisionsor permit shall hce
deemed revoked. BUILDING FEE
n�
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
✓C' I hereby affirm Net here is a construction lending agency for the performance of
V O he work for which this permit is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC FEE
I, r Lender's Name PLUMBING FEE
O V-m Lenders Address do QTY. MECHANICAL PERMIT FEE
1 certify
i(y het 1 have read this application and sum hat the above information is
torte{. legreewcomply with all city urM counry on4innces end sate laws rtlningm PERMITISSUANCE MECHANICAL HE
building construerion,and hereby authorize representatives ofthiscity menta upon the
V above-mentioned progeny for inspection purpsi ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hem les.the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way accecru,against said City AIR 14ANDLING UNIT(TO 10,000 CFM)
in amscqucncc of he gum un i, AIR HANDLING UNIT(OVER 10.000 CFM)
S' nu rent ApplicanOCon Data EXHAUST HOOD(WNUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GTO 100.000 BTU) Deas Receipt#
Will the applicant or future building occupant score or handle Imam us materiel HEATING UNIT(OVER 100,000 BTU)
us defined by the Cupertino Municipal Cads,Chapter 9.12,and he Health and Safety
Cods,Section 25532hd? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE DATE
Will the applicantorfutumbuildinguccupwt useyuipmenmrdevices whichemit BOILER-COMP OHP OR 100,000 BTU) g� r
hmardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Y� •'�
Distria?
❑you ❑No NEW RESIDENTIAL MECH. SQ.IT.
I have mad the hazardous mrerials requirements under Chapter 6.95 of the
Cubarnia Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that C�
if the building does not currently Uveaas t,Jut" my responsibility to notify the
occupant of 0a irrmenu Pricer to issuance of a Canifiwte of urC
OccuPanc fN
PwpfrW auhori ager Dam X TOTAL: ISSUEDBY:
OFFICE