26862 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BOB, ;NG-ELLCI'RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL .�
BUILDING DIVISION BUILDING PROJEC"I IDENTIFICATION
13 UILDI NO ADDRESS: � l SANITARY NO. APPLICATION SUBMITTAL DA'IT
�. ef" .) UNIT# LOTIt Y.�t
OWNERS NAME: PHONE CONTRA R'S NA LIC NO:
• r/y, N/C CONTROL#
ARCIII'I'IiC'1'/IiNc7PER: L NO/ ADDRESS: F-1CONTACT: I/ ,
PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
"DG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
py.L I hereby affirm that l am licensd underpmvisionsof Chaptar9(commencing with JOB DESCRIPTION
1-100_ Section]gp)of Disnion 3ofinns th.Br and Professions Cara.and my license is in PANELS u`l ��
C GV full forte and effect. 1� !�
F6jW License Class Li, UP TO 200 AMPS " —A
m6d Date Cieductor 201-If1011 AMPS
f-D. ARCHITECTS DECLARATION SUIT.FLOOR AREA 8/$Q.ITI'.
ZOin- Iunderstand my,Hns sbzli be used ss public rtdsml,
OZ-❑ OVER IOW AMPS
F in F set SIGNS ELECTRICAL
de =j Liccnsal l'rufcssional
CY«Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
° A., I hereby affirm dust 1 um exempt loan rhe Commons License Law for the
-1'3 LL yfollowing icason.(Section 7031.5,Business wd Professions Code:Any en,or county TEMP.METER OR POLE.1NS'T
E-4'O¢I which requires a permit to conswm,alter,improve,demolish,or repair any structure
to>.:F rto its issuance.also the applicant forsuch Permit file a signed statement POWER DEVICES
prix quirts app permi gn
�C G O that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
SWIMMING POOL ELECTRIC
my5�oC of that nendngwhahere add)the bivision 9ntlheed witanapli Profession Code) VALUA'1]gp{/;
W-m
of that he i31.nmptayapomxnd the bamniisbjecs theaexemant to civil
of r
F7Q
Section 7031.5 by anY applicant fora permit subjects the applicant toacivil penahy of OUTLETS-SWITCI{C�-Po t n I n
0: not mom thin five hundred dollars($500). NEW RESIDENTIAL ELE S .IT. '
❑ 1,asowncrofthepmpeny,ormyemploy«swiNwagns theirwlecompcnsation, Q . ._ I_ _ 1 . TORI TYPE CONSTRUCTION
, es will Jo the work,and theswcture isnot intended oroffered for sale(Sec.7044.Business -` I,.✓ �I
and Professions Code:The Contractor's License Law does not apply m an owner of
property wholumidsorimproves thereon,and whodoes such work himself onhrough Itis
own<mployecs.provided Net such improvcmcros arcnos in¢ndcd oroffered forsele.IL QAA
- 1-13
CC UP RES.UNITS
however,the buildings improvement is sold within oneycarofcompletion.theowner- ]
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,a ndthepmp rtY,a xdusivclyconbactingwithlicensedatnmemrsta
onsbum the p..jet,(Sec.]044,Business and Professions Code.)The Contractor's
License Luwdcea not apply to an mwnernfpropeny who builds or improvezthereon,and PERMIT ISSUANCE
whorontmctz for such projects wish a contmalms)licensed pursuant odte Contractors ALTER-DRAIN&VENT-WATEREA
License Law. ( ) FEE SUMMARY
❑ I nm exempt under Sec. D&P C for this reason BACK FLOW PROTECT,DEVICE, S DL E}F,S
SANITARY Y N
Owner Data DRAINS-FLOOR.ROOF,AREA,COND. RIiCEIr'Tp
WORKMAN COMPENSATION DECLARAI'ION SCHOOLTAX Y N
❑ em'Co offirm pensatonInM1rance or arcate osccopent to frodif f-insure,o.Lab
ateofwhich FIXTfIRFS-PER TRAP RLCEIPI'p
covers alCompeasatlonderttis fioracenifcl copy Nei«f(S«.JeW,Lab CJwhich PARK FIiF, Y N
covers all em to ac's under t. RECEIPT p
p Y petrel GAS-FA.SYSTF;M-1 INC.40UT1,LT5 BUILDING DIVISION FEES
Policy p
Company GAS-EA.SYS'I EM-OVER 4IEA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenificd copy is Gled wiN the cosy inspection division. GREASFJINDUSI'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FFE
COMPENSATION INSURANCE
(This scetlouneed nor hecompletedil thepennit isforonehuniheddollars($100) SEWER-SANITARY-STORM HA.200FT. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is issued.)shall WATER HEATER WNENT/ELECTR
not employ any Person in any manner at)as in become subject to the Workers PAID
Compensation Lawsnf Califomia. Data WATER SYSTEM117REATING Date Receipt#
0Z Applicant
Z Z NOTICE APPLICANT:If.after making this Cenificarc nl'F,xemption,you should NEW RES]DEN'LIAL PLMB. SQ.FT. TOTAL:
` become subject to the Worker's Compensation provisions of the Uder Code,you must
a > fn
orthwith comply with such provisions Of permit shall see deemed invoked. BUILDING FEE
fJ.d Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herchy affirm that there is a construction lending agency for performance of
U Z TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec,309],Civ.CJ
Lender's Name PLUMBING F-
C
C F Lender's Address QTY. MECHANICAL PERMIT FEE
V I certify that I have read skis application and scam that she above information is MECHANICAL FEE
�-' correct.l agree m comply with all city and county ordinances and state laws relaudgm PERMIT ISSUANCE
buildingutmirucdinn,nnJ hereby Bin eprev Ives of this city toenmr upon the CONSTRUCTION TAX
V Z auuve-mentioned property for' tion purposes. ALTER OR ADD TO MECII.
(0000 mgr«to save.' n '(y Lee harmless the Ciry of Cupertino against
Iiralisies,juJgmena is a cswhich maymany weyo rue eg Inst said City AIR HANDLING UNIT(TO 10,000 CFM)
in
vl� �i�ax �'
AIR HANDLING UNIT(OVER 10,000 CFM)
Data I EXHAUST HOOD(W/DUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt p
Will the applicant or future building occupant store or handle hawdous material 11EATING UNIT(OVER 100,IKK1 BTU)
T
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cada Section 25532(-)'1
❑Yes C3 No VIiNTILAI'ION PAN(SINO(SINGLERIiSID)
ISSUANCE DATE
BOILER-COMP UHP OR 100.000 BTU)
Will the appmmunturantor as buil rsed by sad Bay Area it Quality Managemech nt
haxarJoua air comaminands m define)by tM1e Bay Area Air Quality Management BOILER-COMP(OVER 200,000 BTU)
District!
[I Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
I hive read the has#rdous marerials requirements under Chapter 6.95 of the UG 10 19gq
California Hicalth&Safety Code,Sections 25505.25577 and 255]4. 1 urdentand that Oil Y
U
if the building does not currently have a mnam,that it is my responsibility m notify the r hurt
«cupant of the requirements which must he met print to issuance of a Certificate of
occupa',
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE
1