26378 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.C'I'RICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 26378
J C a] �J Q
BUILDING PROJF.CI'IDENFIFICAT'ION L o d I o
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
IZ?3 PV eoin 4,A UNIT LOT
OWNERS NAME: PHONE: CONTRACTORS NAME LIC NO: VVV 111
h =-DIn NO Hale [.L ,X 'L0- R-Ir N/C CONTROL#
ARCHITHCf/ENGINEER: LIC NO: ADDRESS: C
AV �V 3 5 ytW FC-YHFN/Jp Akiii—
ONTACr: PHONE: v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FET,
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 1:1 ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
0yZ I hcm rebyaffirthat l am licensed underprovisionsof0apier9(commencing with
VJ00 Section WIDOW Division 3 of the Business and Professions Code,and my license is in PANELS
fall I Licen wand effect. S
4 License Cans Lic.M 07� UPT02WAMPS
m6y
I'ya - Coaor ria Date
ARCHITECTS DECLARATION SQ.Ff.FLOORAREA 9/SQ.FT,
Z O to201� 000 AMPS
OVER 1000 AMPS
0 L..,p I untlerstand my plans shall be useA es public records.
r H L W SIGNS ELECTRICAL
N2j Licensed Prafessimad
ys2 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0 A. 1 hereby Affirm that I Am exempt from the Contmctor's License Taw for the
u+3 Orn following rcnnm(Section]OJ1,5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
I~�rnwhich requires a Permit to construct,alter,improve,demolish,or repair any structure \
K G� Pmorm its issuance,Also regmires the applicant for such permitto file a signed statement MWFR DEVICESt A t
� �0 ihalhe is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter II
I4,a�ce�' 9(cormencang with Section 700dof Division 3 oftbe Business unit Prefessimms Cade) SWIMMING POOL ELECTRIC .x � �� � uN,{IATION
no, or that he is exempt therefrom and the basis for theallegW exemption.Any violation of OUTLETS -FIXTURES ,�ja
Za Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of _ Jg 5
canot more than five hundred dollars($500E NEW RPSIOENTIAL ELEC It SQ.FT
❑ I,usownerofNeprupeny.ormyemploymawithwagesastheirsolecom ration, T'YPF,CONSTRUCTION
a3— will do the work,and the structure isnotimendedoroffemd for sale(See7uAu.Business
and Professions Code:The Contractor's License Law dons not apply to an owner of
prupeny whobuildsorimpmvesilamon,and whodues such work himselforthrough his OCC.GROUP RES.UNITS
own employees,provided mat such improvemems Are not intended m offered for sale.IL
however,the building orimprovernot is sold within one yearofcampledon,theowner
builder will have the burden of that he did not build or improve se of TOTAL:
praying pnry purpose
sale.).
❑ I,its ownemfthe pmpmeny,um exclusively contracting with((canted cnmrucmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
om,nact the project(Sec.7044,Business and ProfesMism Gnletl The Contractor's PERMIT'ISSUANCE
License Lawdees not apply to an owmerofproperty whobuildsorimproves thereon,and
whecnmructs forsuch projects with acontmctr(s)licensed pursuant native Cmaraerore ALTER (HAI
License Law. FTE SUMMARY
❑ I ar exempt under Sa. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY �Y D S N
Owner —Date RECEIPT p
• DRAINS.FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TA% Y N
❑ are'Coyaffirmthat lhave aceracertiriede senttoof(Smure,0,1,nb .)whiof FIXTURES.PERTRAP RECEIPfp
Warkeri Cnmpenxationlnsurunec oracerhfied copy thereof(Sec.JA0f1,Lah CJ which PARK PEE Y N
rs all empiny<e's under this permit. GAS-P.A.SYSTEM-]INC. okETLHTS RECHIPI'll
Policy N BUILDING DIVISION FERS
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHE.CK FEE
❑ Cenifiedcof,micarebyfumished.
❑ Cenifed copy is fled with the city inspemian division GRPASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHMAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars SHAfi SEWER-SANITARY-STORMEA.200FT. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATTiR WNENT/ELECI'R
not employ any person in any manner sit es to become subject um @e Workers' PAID
Compensation Laws of Califormla. Ilene WATER SYSTEMITREATING Date Recciptp
Q z Applicant
NOTICE.TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F Vl became sAjecuo the Workers Compensation provision afdan Labor Cale,you must
� ; forthwith comply with such provisions or this permit shall be deemed invoked. BUILDING FEE
0. A - CONSTRUCTION LENDING AGENCY SEISMICFEE
7 z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the weak for which this permit is issued(See 3007,Civ.CJ
Lender's Name
OULe ter',Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W1 certify that I have read this application and state that the above information is
ie MHCI IANICAL FET.
correct,]Agree to comply with all city and county ordinances and state laws mining to PERMH'ISSUANCE
rA building construction,and hereby umharim representatives of this city to enter upon the CONSTRUCTION TAX
U z diuvememioned prpeny for inspection puryoses. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino Against
Iiadlities,judgmeno,castsand expenses which may inany way eccrueageirt said City AIR HANDLING UNIT(TO 10}100 CFM)
in cmoucktam,,p`f the grating of Nis permit.
1 ✓/� _ /�-
s i10,000(' AIR HANDLING UNIT(OVER 10, O CFM)
Signatureof Applicant/Contranor Dare T EXHAUST HOLD(W/DUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)BTU) Data Recciptp
Willtbeappfiwam or fair.himld.,eceapant store or handle lumadmus material HEA]'INO UNIT(OVER 100,000 BTU) '1'O'I'AL:
as relined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Cale,Section 25x, x)1 13 No
0Yes VENTILATION FAN(SINGLE RESOD)
W ill theapplicantorfmumbuilJingoncupantuse equipment ordevices whichemit
B0ILRR.COMP(3HPOR 100,00011111) ISSUANCE DATE
harallor air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DisWet3 4
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,PT, P A
1 have read the haxmdom mmefaaas requirements under Chapter 6.95 of the DAY q d
CuliOmntia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that 11s
,fire building does at curen0y have a tenant,that it is my rcspmsihility to notify the
occupant nl the���yyJI11 vements which must be ma prior m issuance of a Certificate of
Occupancy./ {"u N t HIV`1
Owner or d1thimund agent Date TOTAL: ISSUED BY: V
OFFIC