26818 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING ELECTRAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL 2 6 8 1 8
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Ito I � 1 Pkar La Dr. UNIT# LOT4
OWNI:R.w AMP.: -ru� � -pO?N� CO ACTOR'S NAMP.: ro� s LIC NQ: N/C CON'1'K0I.g 111
RCHITECT/ENGINEIN: PLIC NO: Al S. _C+kfdVv_11 -S�4 ,e 9 //_r//� 0
CONTACT: PHONE:
Q'I'Y, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED
COMRASDIC1A�RAT
10N APPLIANCES-RESIDENT IAL LOB DESC
QThereby hatL nsednerpro ifesoenwith
i02 Section 7W0)orDivision ofthe Business and Professions Code andidyliaenteiin PANELS
, fuilclrnfomeandeffc . wWZt
F '
�
Lic.# 1� UPTO200AMPS A/)
re,6 y Dam Contmaor 201-IOW AMPS
Fy ARCHITECT'S DEC.ARA'1'[ON ��� s IS II SQ, rT.FLOON AREA 8/SQ.PT.
OZ—a OVER IO_ M Op'`Vp
O t�•q I underhand my Athos shell he used as public recons. �•
ntw SIGNS ELF.CIRCpI. ` / 1—^ �"' ^
4�d Licensed Professional \
L���'U OWNER-BUILDER DECLARATION SPECIALCIRcgrr/b C.a ( �I � � u
ippiS5,,OyU 1 hereby ofinn that 1 am exempt from the Commclins License Law for the
ts+LLQm following reason,(Section 0031.5,Business and Professions Cede:Any city or county TEMP.MF.TER. RPOLEINST.
which requires a permit to comw<L ulmq improve,demolish,or repair any structure N I
F Y prior to its iuuance,also requires the applicant for such permit to file a signed smmment POWER DEVIC
G0 Choi he is licensed pursuant o the provisions of the Contractor's License Lew(Chapter
WXa OFg 9(cnmmencing with Section 700))of Division 7ofthe Bintimosund Professions Code) SWIMMING POOL ELECTRIC VALUATION
Wim or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-PI%TIIRES
ryaSection 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
z not mom then fee hundred dollen(5500). NEW RESIDENTIAL ELECIR S .FT.
C� ❑ I,asnwneroftheprnperty,ormyemployecswith wagesestheirsolecompcnsation, Q STORIES TYPECONSTRUCTION
a wit Ido the wurk,md the structure is not intended or offered tarsals(Set.]044,Business
and Professions Code:The Contractor'a License Law does not apply to an owner of
progeny who buildsor initiatives thereon,mal he doeaauch work hinnest through his OCC.GROUP KFS.UNITS
own employees,provided Nat such Improvements amnot intended or offered for sale.IL
however,the building orimprovement is sold within oneyear of completion,the owner. TOTAL:
builder will have the human of proving that he did not build or improve for purpose of
sale.).
❑ Lasowner ofthe property,annexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.104,1,Business and Profeuiom Code:)The,Contracmts
License Law docsnot apply toun ownerofpropeny whobuildsor improvesthereom,and PERMIT ISSUANCE
who contracts forsueh pmjects with it contuartma)licensed pursaontto the Contmetor's
Licnse[,aw. ALTER-DRAIN&VENT-WATER(FA) PEE SUMMARY
e
❑ l am exempt under Scc. ,B&P C for this rcawn BACK FLOW PROTECT.DEVICE SANITARY Y UN
Owner Data RECEIPI'p
COND
AREA,, .
WORKMAN COMPENSATION DECLARATION DRAINS-fLOOR. SCHOOL TAX Y N
❑ era'Coyaffrmthatlhave a rance in certificate of consent pythmof(Snsurc,m LAb C.)c which
RECEIPfp
FIXTURES-PER TRAP
Workcri Compensation lnstuancemacmified copy thereof(S<c.7800.InbCJ which PARK FF.F. Y N
coram all employee's underthis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEMAVHR 41EA) PLANCHECK FEE
❑ Cenifed copy is hereby finished.
Certified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS[ZEE
COMPENSATION INSURANCE
(This section need not he completed Blue permit is fortune hundred dollars($100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
or less.)
I certify that in the performance of the work for which Nis pemtit is issued,l shall WATER HEATER W/VENDELECIR
not employ{�an�2'person artery manner so rh t to the Workers' PAID
Z ACom licunt t'LfV�if.ICalifomiu. ❑me WATER SYSTEM/TR Date Receipt#
O pp
NOTICIi '. f makingthis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L• in become subjecuo the Workds ntpemadon Provisions of the Labor Code,you must
? forthwith comply with sucbprov 'ons or this permit shell be domed revoked. BUILDING IEE
W Z CONSTRUCTION LENDING AGENCY SEISMIC PER
5 1 hereby affirm that there is a construction lending agency for the perf rri of TOTAL: ELECTRIC TGE
U Or the work for which this permit is issued(Sec.3091,Civ.C.)
U. t"' Lender's Name PLUMBING FEE
O U Lender'a Address QTY. MECHANICAL PERMIT FEE
I codify that 1 have read this application and state that the above information is
come,.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingeomwction,and hereby authorise se
reprentatives of this city tueater upon the CONSTRUCTION TAX
above-mentioned d
nonert
U Z ProPe y for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liubilitics,I lgan m,cmtsandexpenuswhichirey inanywayst.om.gainstamiidd City AIR HANDLING UNIT(TO 10,000 CPM)
in cnnseyt m tbfingof this peraiL I'- L AIR HANDLING UNIT(OVER 10,"CFM)It
L
Signa��pPlie at/Cmuo paeMCmuo Data EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) 1 Ilam Receipt#
Will the applicant or future building recursion store or handle Exudations material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cook,S coon 25532(e) NVENTILATION FAN SINGLE RUSH) 4"
❑Yes o
BOILER-COMP(3HP OR IRL"BTU) ISSUANCE DATE
Willtair contaminants
defined
be the ay equipment oath c Management W p 0 ,0
hawdous air contaminants m defined by the Rey Ante Air Quality Management BOLLEN-COMP LOVER dfXI,OW BTU) ksd
Disvicft l�s(I''
❑Yes N. NEWRESIDENTIALMMIL SQ.IT. AUG a
I have read the b/azardo`us materials rcquimments under Chapter 6.95 of the 199
Califnmiu lhealth&Safety Code,Sections 25505,25533 and 25534.1 understand that C//
if the huildiif the ntcurrently have a tenant,that it is my responsibility to ready t it have o tenant,that it is my resposibility to nobly the ��l/' bys-
Occup m rc vanems which must Ix met prior to iseueyCA o' fy�t�
Owner or smhoriaed agent Date TA ISSUED BY:
OFFICE