26889 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DHIU INR:-ELRCTRILAI, PERMff NO.
APPLICATION/PERMIT PLUMBING-.MECIIANICAL /k/1 /�/��a
BUILDING DIVISION RuB.DLNG PRoiRcL'r TURN"IIFICA1H N \6 \8�8 9
BUILDING ADD//RI1I((S''Sy�:11�\ SANITARY NO. APPLICATIONSUBMfITALDATE
C�J LOT#
OW EN RSN :� C( R
W CON'fROI,p
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TECT/[iNGINEE0.: LIC NO: ♦ [S$: �\ �,vW` � L'
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECTLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
==Z I hereby affirm that l am licensed under provisions of Chuper9(commenciagwida OB DESCRIPTION
4]UN Section s card e f Division 3 of she Business and Rofession Cade,and my license is in ppryPyS
FK W full force snit cffc
Zu1 LicenLic.x UP T02W AMPS
ryQa Date Contractor 201-IOW AMPS
FyZ ARCHITECTS DECLARATION OVER I"AMPS
FySQ.FT.FLOOR AREA 8/SQ.FT.
C Z L' I understan plans shell be used as public records.
�� SIGNS ELECTRICAL p
�WCGLicensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ;' II [—� D B
KOaU T hereby affirm shat 1 am exempt from the Contractors Liccrom Low for the f
W3LLy following reason.(Section 7031.5,Business unit Professions Code:Any city or county TEMP.MEIE0.0R PoLE INST. / '\JjP I ^
which reyuiresa pemnit mconswct.vlttt,improve,clannish.m¢pe'v any awe[ure xxx111..•111»> P4/
5nn y prior to its Issuance,also re,irestheapplicunl ftrsuch permit m file a signedsutemem POWER DEVICES I
I WK C that he is licensed punoanuo the provisions of the Contractors License Low(Chapter SWIMMING POOL ELECTRIC
o.ao� 9(commencing with Section]000)ofDivision3 ofthe Business and Professions Code) DAT V ON
Wim or that he is exemprtherefmm and she basis for the alleged exemption.Any violation of 1
FZQ Section 7031.5 by any applicant for a Permit subjects the applicenfto a civil penalty of OUTLETg-SWITCHES-FlXTURES
ggo nut momthvn five hundrWdollnrs($5(10)
cat:, ElI.osowneroflhepmRay,ormycmployecswiJwagesssthirwiecomp=Don, NEW RESIDCNTIAL ELECTR _SQ.FT. STORIES TYPECONSTRUCTION
y3_e will dofessiosCdthestr Contractor
a License
shot apply to an Business
and Professions Cade:The ves lmroon,License Ise such
not apply m an owner of
own em whobuildsorfmpnweschcrenn,andwhodocssuchworkhimselfedifunugh his
cmployees,providedthal such impmvemenemc not in¢ndedmoHeredforsUe.If. OCC GROUP RES.UNI"IS
however,the buildingorimpmvemetn is sold within one year of completion,the owner
builder will have the burden of proving that he did mat build or improve for purpose of '10'AL,
si1c')'
EI 1.as nwncndthc property,umaclusively, contracting with licensed conwnorsQTY. PLUMBING PERMIT FEE
m PLOOU LUNB APN
constructa4,the project(Sec.9DBusiness and Professions Code:)The Contractor's
License Law does not applYmmownerofpmMny whnbuildsorimpmves lhercnn,and PERMIT ISSUANCE
whocantransfor such projects with aconanctar(s)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OUT SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have acenifcam ofcoment loself-insure,macenificatao( FlXTURLS-PER TRAP RECEIPT#
Workers Compensmion l^suunceora certified copy Ncrcaf(Sec.38M.Lab C.)which PARK FEE Y N
covers all employees under his permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECRIPI'b
Policy x BUILDING DIVISION -,ES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Candied copy is hereby Imposed.
❑ Certified copy is fled with Ne city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPHON FROM WORKERSORLi SI?TRAP SOILS FEE
COMPENSATION INSURANCE
('Deis section need rot be completed ifthe permit is forone hundred dollars($100) SEWER SANITARY-STORM EA.2WF1'. ENERGY FEE
or
I canlfy that in Ne performance of Ne weak for which this pcmnil is isms I shall WATER HEATER W/VEN'DELECTR
nut employ any person in say manner so as to became subject to the Workers PAID
Compensationlswsof Califamia. Date WATER SYSTEM/MPTING Date Receipt#
zz Applicanl
0 NOTICE TO APPLICANT:If. frtr making this Canificato of Excmpfion,you should NEW RESIDENTIAL PLMIL SQ.It TOTAL:
fq become subject o the Worker's Compensation provisions of the Labor Code.you must
a - fonhwih comply with such provisionarshis pemtit shall bcdeemedrevoked. BUILDING FEE
OW.. Q CONSTRUCTION LENDING AGENCY SEISMIC IPE
1 hereby affirm that is a construction lending agency for the perfomunx of
7 z 'he ,,,it for whichlhis t is issued(Se,3M7.Civ.C.) EL[CfRIC IPE
U Q I<ders permit
nName PLUMBING FEE
u" F 1<ndcrs Address QTY. MECHANICAL PERMIT FEE
O U I certify that I have read this application and mum that the above infor m 1.is MECIIANICAL.FEE
com O. lagreemcomply withell city arl<oumyardinvtces and stain lawsrelatingto PERMIT ISSUANCE
N building construction,and hereby aushmize repraenutivesofshiscitymemerupenthe CONSTRUCTION TAX
U Z abavemommard property,for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and keep hmmless the City of Cupertino against
liabilitimajudgmenb,emsean cxFrom Nch waym any way accrueegeimst said City AIR HANDLING UNIT G 0 10.WO CFM)
In tyucncc aft cgmminy fshis pett� k
11 AIR HANDLING UNIT(OVER 10.000 CPM)
Signature of Applic^nVConmctor\/ Date I EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,00p BTU) Date ReceiptN
Will the applicant or future building occupant store or handle hazy Ivcx material 'I'OTAI
as defined by the Cultenino Munici find Code.Chapter 9.12,and the l health and Safety HEATING UNIT(OVER I W,OW B'I U)
Cade,Section 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Ycs ❑No (� ISSUp�'CE DATE
Willthca dicer nrlumrcbuilJin mac tordeviccswhich emit BOILER-COMPUHP OR IW,000 BTU) u IS UI W;
pp d by the Ana
Air
M1azardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER IW,000 BTU)
�District? ❑Yes 0N NF.WRESIDENMALMECH. SQ.FT. Al—JIG 8 1994
1 hove read'be hazardous materials confinement., Chapter 6.95 of the Cl/�, s�
California Health&Safety Code.Section 25505.25533 and 25534. I understand Nal UI' I'V CI11 IIY
if the building does not currently have a tenant that it is my responsibility to anifythe \ r U
acupant of the reyuiremenb which muss be ren prior tu issuance of o Cenifirarc of
eapanry.
Owner or.ammized agent Date 1 ISSUED NY:
OF C