26787 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO �1NG-MECHANIC ' PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PIAMBING-.ADEN I WICA
BUILDING PROJECT IDEN'I'IFICAI'[ON 26787
BUILDINI ADDRESS: SANITARY NO, APPLICATION
^SUBMRTAL DATE
UUNIT# LOT#
OWNS S AME: {k//...ms�sa PF NU: CONTRACT'OR'S NAM t. ^C I NO `V7
S G\Qr q V�� � � NC CON ROC#
ARCHITF.C/ENGINEER: LIC NO: ADDRESS:
COM'ACT: PHONE: ❑
1'r Q �7? O� 9 QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
�.a V L ELECT PLUMB SUCH
PF"n,ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC
QWz Iherchyafr,.that l am licensed unde,rovisienof Chaptar9(commencing with
Iz100 Section 70m)of Division 3 ofthe Business en ProfessionsC dmylicenuisin PANEL
,F<Z, hall forceand effort t�t e� d n ( I
ZWE Licenu Clas effort i<.p V UPTO]OOAMPS
m=y Dwe Contractu 301-I000AMPS
Z O,z 10CHl'fF.CTS DEC RATION OVER 1000 AMPS SQ.FT.MOOR AREA $/SQ.PT.
OZ—,Z
1 unJemm�d my plans shall h used us public rtcorda.
F W SIGNS ELECTRICAL
�� Licensed Pmfnsional
�K6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aµµa35 O W U I hereby affirm that 1 am exempt from the Comforter's License Law for the
u+3am¢ followingreasoa.(Section]031.5.Business and Professions Code:Any city ormarty TEMP.METER OR POLE MST,
J which requires a pe.it m construct,alter,improve,demolish,or repair any affae]urt
o, prior m it,issuance,also requires theapplicant forsuch Aconine fileeaigned smtement POWER DEVICES
p ]hot he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencing with Sectio 7")of Division 3 of the Business and Profession Code) SWIMMING POOL PT RCRIC A''^ VALUATION
W=rn orahat tion 7031.5 by uhercbnmand the basis Permforthects thedexemant to civiny l
of OUTLETS-SWITCHES-FIXTURES
FZa Section]031.3 by any applicant fore permit subjects the applicant ecivil penalty of
W � not morethan five ftheprc ny,odollars($300). NEW RESIDENTTALELECTR _SQ.PT. STURIPS TYPECONSTRUCfION
❑ Lmownez,and thropamy,orm otimenyecswlthwagnastbeirsol.compensiness
a3-. will dothe
asarms ndr:no Crtisnors Lienee ffered Law
ntapply to., wane of ,
trod Pmfnsinns Clair:TTe Comracmr's License Lew does not apply w an owner of
property,whohuildsorimprays thercon,and whodcessuchwmk hintnelforthroughhix OCG.GRGDP RES.UNIT%
ownemployus,provideJthat wchimpmvmnemsercnot imendedoroffercd forsele.If,
howeveq the building or improvement is sold within one yearofcompledort,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale J.
❑ Los ownerufthepropery,am exclusively contracting with huoveontranmam QTY. PLUMBING PERMIT FEE ROOD ZONE APN
onsuum the project(Sec.7044,Business and Profeuion Cmix:)The Column is PERMIT ISSUANCE r
License Low does not apply manownarofproperty who buildsmimprovestheron,and 1
whocontrets forsuch projects withacorhmmr(s)Iimmed ammanttothe Contractors ALTER-DRAIN&VENT-WATER PA F UM ARY
License Law. ( ) - �. .
ES
❑ I run exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE ) /I I,-IsAkITARY N
Owner Dem DRAINS-FLOOR,ROOF,AREA,C D. ECEIPT#
WORKMAN COMPENSATION DECLARATION Y N
❑ Ihcrthy nffirm thmlhuve accnifcete of comm roulGirmurt,orattmificateof RECIi T#
Workers Com nsationlnsurancenracertificdc FIXTURES-PER TRAP
covers all pc spy thertaf(Sec.JgIXl,1<b CJ which Y N
P Yees unJ�r isP GAS-EA.SYSTEM-1 INC. OUT, "-RP .PTA
xV\. Pulicy# BUILDING DIVISION FEES
Ccompany a� 7� �', g /a GAS-EA.SYSTEM-0VER4(EA) PLANCHECK FEE
❑ Cedified copy is hereby famished.
Cemilied copy is filed with the city inspection division. GRP.ASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action need not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the wad for which this permit is issued,l shall WATER HEATER W/VCNT/ELECIR
not employ any Person in any manner so n to home subject to Lie Workers' PAID
Z Compensation Lavaof Celifomia. Data WATER SYSTF.MIMEATING Data Rceeipt#
Applicant
.�� 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
r VJ become subjem to the Worker's Compensation provisions of the Labor Cwle,you must
�i 7 forthwith comply with such provisiova or this Permit shall be deed FEE
revoked. BUILDING
0. �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby effint that them is a contraction lending agency for the performance of TOTAL: ELECTRIC FEIi
O the work fm which this permit is issued(See.31197,Civ.CJ
Lender's Name
O U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have rad this apflictainn and state that the above infounanian is
correct,l agree to comply with all city and county ordinances and state laws riming m PERMIT ISSUANCE MECHANICALIEE
rA buddingcommction,and herby outho serepresentmives ofthis city to enter upon the CONSTRUCTION TAX
V Z ubove-mentioned property for inspection purposes, ALTER OR ADD TO SUCH.
(We)agree to save.indemnify ad kap harmless the City of Cupertino against
I.1ilums,judgmem. cats and expenses which may in my way ammeagaln]said City AIR HANDLING UNIT LTD 10,000 CFM)
in consequenc 'I ruming of this permit. s.
/YW':j,C'd,J/ ATR HANDLING UNIT(OVER 10,000 CFM)
f .mrc PPlmmVCma.etm U at, EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,0m)BTU) Date Rweipt#
Will the applicant or future building ucenpot star or handle hmnrdous material
os refined by the Cupertino Municipal Code.Chapter 9.I2.and the Health and Safety BEATING UNIT(OVER 100,00)BTT) TOTAL:
Code,Section 25332(a)7
❑Yes ❑No VENTILATION PAN(SINGLII RESID)
Wit]theepplican]orfmuubvilding occupumuseequipmenmrreviceswhichemit
BOILER-COMP(3IIP OR 1 W,01s)BTU) ISSUANCE DATE
hazardous It contaminants u defined by Ne Bay Area Air Quality Management BOILER-COMP(OVER� IOO,OW BTU) p 1f District? H'i y
❑Yea 1:1 No NEW RWIDIIN'I'IAL MECH.—SQ.FT.
I have rad the hur rdous materials requirements under Chapter 6.95 of the JUL 25
Californiaalih&Safety Co,i ,Sections 23303, 5533 and1 understand that19940)
ifthe building does not cum, lyhaveamar. it.it is my responsibility to notify the Cqy!
occupant of the rcquinem which must k met prior In issuance of a Certificate of to I
Occupancy. a.., f' /
Owner or m gent l ]e TOTAL: ISSUED BY:
OFFICE