26448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL DI G-MECHANICA PERMIT NO.
APPLICATION/PERMIT PLUMB
BUILDING DIVISION BUILDING PR,JF.GT IDENTIFICATION 26448
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT# "Y-5r—A.
OWNERSNA 0,0 ac HANE: CONTRACTOR'S NA LIC NO: NIU CONTROLp
ARCHTE-CT/[NGINEER: ICN,: AD RESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDF,NTIAL
pyz Inercbyaffnmthatlam licensed underprovisions of@ap¢r9(commencing with JOB DLSCR ION
wi1O0 Section)Oof DivisionJof the Business and Professions Cade,end my license is in PANELS
<UF roll force andad clfect.
FZm License Class LIcN UPT02MAMPS
y 6 vai DaeComranor 201-1000 AMPS
z0OVER ARCHI'I=S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
07—M 1 understand my plans shall be used as public recoNs.
y F; SIGNS ELECTRICAL
.4 Licensed Pn ficc,mnul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOaU I herchy affirm that 1 am exempt from the Contractor's License Law for the
u13 ay which
following reason.vSectlnn exactor ,BusinessandProfessions Code:Any city or county TEMP.METER OR POLE INST.
Ft='ON; which requiresn permit mconstrue,aper,improve, paromiitt fie.siiganyunscmm
C,Q0 prior that
disused palsorequires formom Copermieo filLicense
Use
namment POWER DEVICES
ty C p ma he is licensed pursuing to the provisions of the Conweror's License Law(Chapter
S X.a' 9(mmmencing with Section)1100)of DivisionJof the Business and Professions Coda SWIMMING POOL ELECTRIC VALUATION
yl_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
FZ_Q Section O031.5 by any applicant for a permit subjects the applicant to a civil penalty of
no more man Bvc hundred dollars M W).
K�p ❑ I,azownernfthepropeny,ormyemployeeswith wagesas mcinNccompensaim, NEW RESIDENTIAL ELECTR —SQ.F.' STORIES TYPE CONSTRUCTION
y3=e will do the work.and the structure Isom intendd44,oroffered for sale(See.90Business
and Professions Code:The Contractor's License Law does not apply m an owner of
propenywhobuildsorimVromavesem.andwhodoes such work himselrarthrough his
employees,provided that such impravementsa¢notimendodoroffeml forsale.If. OCC.GROUP RES.UNITS
however.the building orimpnrvemem is sold within one yemof completion,the owner- TOTAL:
builder will have the burden of proving that he did amt build or improve for purpose of
sale.).
❑ I,as owncrofthe pmpeny,amexclusively contracting with licensed contracmrsm QTY. PLUMBING PERMIT FEE FLOODZONE APN
cammet the project(Sec.7044.Business and Professions Code)The Contractor's
Ucenselawdocsn(iiaMlytoonownerofprnpenywhobuildsorimprovc,thereon.andPERMIT ISSUANCE
who contracts formeh pajects with a contractors) pursuant licensed pursuano the contractors ALTER-DRAIN&VENT- ( ) FEE SUMMARY
License Law. WATER EA
❑ I em exempt under Sm. B&P C for his reason BACK FLOW PROTECT.DEVICE OUTSIDE MES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT is
WORKMAN COMPENSATION DEIO
CLARATN SCHOOLTAX Y N
❑ Iherehy affirm thntlhaveattrtilicnm of consent ro self-irtsum,macenifcam of FIXTURES-PER TRAP RECEIPT#
Workers Compensation Insurance ora certified copy thereof(Sce.3800,Lab C.)which PARK FEE YemuN
m rill employes',under this permit. GAS-HA.SYSTEM-1 INC.4 pUTLETg RECEIPT#
Company
# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA)
❑ Cenilid copy is filedherebyw th the d. PLANCIIECK FEE
❑ Ccnilied copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEzE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('ILis section need not be completed ifthe permit is(orose hundred dollars IS[Bob SEWER-SANITARY-ST'ORM EA.200FT. ENERGY FEE
or less)
Icenify mm in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECI'R
not employ any person in any manner so os to become subject to the Workers' PAID
Compereatioulawsof Califomia. Date WATER SYSTEMITREATING
Q z Applicant Dam Rcccipt#
z 2 NOTICE TO APPLICANT:If.after making this Cenifhcau of Exemption.you should NEW RESIDENTIAL PLMIU SQ.Fr. TOTAL:
F-' Ln become st
subject to the Workers Compensation provisions of the Labor Cade,you mu
7 Smooth comply with such provisions or this permit shall be domed revoked. BUILDING FEE
per, A CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that men:is a contraction lending agency for the perfommnce of
V O the work far which this permit is issued(Set,3097.Civ.C.) TOT I ELECTRIC FEE
Lender's Name
ULennert names QTY. MECHANICAL PERMIT PEE PLUMBING FEE
�" W ro 1 cmify that 1 have read this appliatien end state that the above information is
6. mea.lugreeI ply with a 11 city and county ordinances and nate laws refining to PERMIT ISSUANCE MECHANICAL FEE
buildingotooluro ,andhcrebyaum presenhativcsof this city to enter upon the
U z above-mention perry"'mpe ran mpous. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(We)o e n save,indcmri keep M1nmless t f Cupenlno agapin�st
liubilitj ts.cosu and swM1ich racy ins cflifila.5p AIR HANDLING UNIT(TO IO,00)CFM)
in cc rthe grantito uPe 't. ^-�
1 AIR HANDLING UNIT OVER 10,O001 CFM)
sign plc UCoa me. Date P.XHAUSTHOODIW/DUCT)
PAID
HAZARD S ATF,RIAIS DISCOID URE HEATING UNIT(TO I00,O00 BTU) Date Receipt#
Will the applicant or to c hiding occupant store or handle bmardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,ondihe Health and Safety BEATING UNIT(OVER 100.000 BTU) TOTAL:
Cade,Section 25532(a)'f
1-1 Yes 0 N VENT'ILAT-ION FAN(SINGLE RFSID)
Will the applicant or future builJingaccupant uuequipmemmdevices which emit
BOILER-COMP(3HP OR 100,000 8W) 'ISSUANCE DATE
• heardous air conrumitunrs us Defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) RA A B D
D1nma'1 6' P4 D
❑Yss ❑No NEW RESIDENTIAL MECH, SQ,FT.
I have read the h—dous mmcrials calmammts under Chapter 6.95 of the MAY
�/ O 7 1994
(I�rf
Califomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that '1i'A t�.L wl 4
if rhe building does not currently have a mnerm that it is my responsibility to notify me
Occupup at arae reyahernemt wmen nen m met poo to issaa ee ora emirate or CI I Y Ut wren 7 uVl�
Occupancy.
Ownerminflu i,ol agent Date TOTAL ISSUED BY: V�1
OFFICE