26332 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDS IG-ELEC'TRI AL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26332
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS/` ��•�.,��..[. ��2SANITARY NO, APPLICATION`SUBMITTAL DATE LOT 0. /
PHONell. C NTRACT 'S NAME: ICN : NIC CONTROL.To
SRCHITECT/ENGINEER: LIC NO: DD ESS'.
Iry Oe•
CONTACT: • PHONE: ^ x BUILDINGPERMITINFO^
QTY.' T rtHLHCTRIC PERMIT FEE
ELECT PLUMB MUCH
PERMIT ISSUANCE:
LICENSED CONTRACTOR'S DECLARATION pppl.lANCF.S-RESIDENTIAL
Ra700 [Ormiston 3mlice,Business Ch tag commumin Ib v�
�y hereby provisions. p ( gwi
00 Section]000).f Dlvision3 nRhe Business and Profen§�ns Code,and my license is in PANELS �
QdEfull force and effect. li/_Q
4 License CII Lic.# •'l•I UPT02MAMPS
Ito 6 ti Date Contmct.r 201-1000 AMPS
ZOyZ R ITECTS DF,CIARATION OVER 1000 AMPS SQ.IT.FLOOR AREA !;/SQ FT.
O Z—G I understand my plans shall he used as public retools. _
BI SIGNS ELECTRICAL
6�n
' Ij Licensed Professional
�Cda'a OWNER-BUILDER DECLARATION SPECIALCIRNIT/MISQ If �ss�
OyF I hereby affirmdrat 1 am exempt from the Contractor's License Law for the s _ q n e
rpm followingreas.n.(Secnon]031.5,Business and Pfinessiaw Code:Any city.,county TEMP.SIFTER OR Pli INST. I. L �� LJr tl�
se m.Q] which requires a pemtit m nmsmua,uimq improve,demolixh,nr repair any stmcwre ( j/
se a,
prior issuance,also requiresfieapplicant for such parotic.fileesigned stmemenl POWER DEVICE
ii I.
J
OO that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter Il
apoK 9(commencing with Section]00(7of Division 3oRhe Busineseand Professions Code) SWIMMING POOL ELECTRIC VA
i,!2, or that he is exempnherefrom and the basis far twi legcl exemption.Any violation of OUTLETS-SWITCHCS-FIXTURES
Za Senim903L5 by anyapplicam lora permit subjects the epplicanno ucivil penahy of
SSG not m.rethan rive ha dreddollars($500). NEW RESIDENTIAL ELECTR S .Ff.
F , ❑ I,asownerofthepropeny,ormyemployeeswithwagesastheirsolecompensudon, Q STORIES TYPECONSTRUCTION
.W.q will do the work,and the structure isnot intended orofferedforsale(Sec.]04Q Business
and Professions Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,anti who does such work himself or through Itis
unploycc,p..vlded that such impr.vemente am n.HntendW orofferedforseIt.If. OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofcnmpktion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.)
❑ I.as owner ofthe property,am exclusnelywntmeting with licensed contractors to QTY '- `+ r PLUMBING PERMIT- :vPGE; . FLOOD ZONE APN
construct the project(See.9044,Business and Professions Code:)The Contractor's
License Law does not apply t.anowneroToopenywh.buildsorimproves thereon,and PERMIT ISSUANCE
who contracts mrsuch projems with acomructor(s)licensed pursuant no the Contracture ALTER Li.utse Law. (EA) i ( ; ,j FE-P.SUMMARY -,
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE F.ES
SANITARY Y N
Owner - Data DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that l have a certificate nFconsennoself-insum,oracedifiwte of FIXTURES-PER TRAP RECEIPT#
Walsors'Computsati.n Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK PEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RGCL'IPT#
Policy la BUILDING DIVISION FEES
Company
❑ Certified copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE �s
❑ Certified copy is fled with the city inspection division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP
SOILS FEE
COMPENSATION INSURANCE
(This secJon need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
carless)
I.enlly that in the perfomianeeofthe work for which this permit is Issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as te hec.me subject m the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEM/TREATING Dom Reactor If
Z+ Applicant
Z 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
1-+ Vj become subject o the Workers Compensation provisions of the Labor Code,you must
Fa' 5"' forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
QZ. row
CONSTRUCTION LENDING AGENCY tSEISMICEE 1 herebyafrirm Ihm there is a eonstiucdon lending agency forIlioperfonnanwofV Othe work for which this permit is formed(Sec.309],Civ.C.) T �� FEELea sNam. orCLenders Address QTY (' MHCHANiCAl PERMIT s :-FEE G FEE
I certify that 1 have read this application and state that the above informant e r -
W correct.I agree to comply with all city and county ordinances and state laws testing to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives ofthis city to erderupon the
V Z rimae-mentioned p.,o,for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
OV.)agree to save.Indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may In any way acerae against said City AIR HANDLING UNIT(TO 10,1)00 CFM) -
in conj a tgm his permit.
/ AIR HANDLING UNIT(OVER 10,000CFM)
Signe a oo actor Dat EXHAUST HOOD(W/DUCT7 =Rdceip,
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00013M)Will the applicant orfuture building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Cale,Section 25532(a)'1
Yes 11 No VENTILATION FAN(SINGLE RESID)
❑
BOILER-COMP CHIP OR 100,000 BTU) FpISSUA'NGE,DATE
Will lhexpplicantor futureb.ildingrtccupant useequipmenmrdeviceswhich emit i"' PP95 (V/
h cord r t defined by the Bay Area Air Quality Management BOILER 100,(100 BTU)
rie„r 41 1994
11 Yes nminenO Na NEW RESIDENTIAL MECH. SQ.IT. MAY �,2
I have read the hazardous mmentils requirements under Chapter 6.95 of the C�-�� U"California Health&Safety Code,Sections 25505,25533 end 25534.1 mderstand that
if the building does not currently have a tenant.that it is my responsibility to notify the 4Uf Ln t u i�/
occupant of the requirements which must be met prior to Issuance of a Certificate of
occupancy.
Owner or authorized agent Date TO ISSUED BY:77�
OFFICE