26707 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Rmnlm-,-bLarCI'RiCAI' PERMITNO.
BUILDING DIVISION APPLICATION/PERMPI• PLUMBING-MECHANICALCT26707
BUILDING PROJE 'IDRN'1'IIVCA'1']ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
9a3 �� DNIT# LOT# IO G �1
O •Rg AM NAII,rskgNE: 1 O TRMORS NA\ epr l/I
I i .�/�. N/C COMIHOLp
•ARCI111 ECN INEFR: LIC NO: - y ADDRE.S: :N`I
CONTACT: PHONE:
QTY. - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELE PLUMB MEC
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
awz I herebynffrm thutlmm liccnsed undapmvisionsofChapmr9(commenoingwith
POR F Section]0007 of Division 3 ofthe Businessend Professions Code,and my license is in PANELS
6i-,V full Jenennde �nnlfV Q
FZ, Liccns Lie,a3540 P 0200 AMPS (yV�
6, Dmm _ Cnmractor 201-1000 AMPS S IT.PhOOR AREA S/SQ.IT.
ZONZ ARCHITF.CI'SDC #TION OVER IIXI(IAMPS Q
OZ-0 I undersmnd my Plans shall 4 uud as lie morals.
ry Ful SIGNS ELECTRICAL
g5 Licensor Prnfeeslonnl -
OWNER-exempt ER DECLARATION SPECIAL CIRCUIT/MISC.
ip�.OaLU 1 hereby affirm that 1 am exempt from the Commix Co License Law for the
N 1�z ,N following Tiresa Permit
to co31.5,Businessand Professions Co de:My city orcctine TEMP.MEfER OR POLE INST.
F lLo which regnires a permit m constmct,neer,improve,demolish,or repair any swcture
>r r 10 its isman,eaBorc (hes licant for such uo file.signedstatement POWER DEVICES
Ano tubes pp pberr
00m that he isnilicensed w forment
Section
0,e pn,vislnns of the Convenors License Law(Chapter
LXOW )(commencing with Senion]O(()of Division3of the Business and Professions Cale) SWIMMING POOL ELECTRIC VALUATION '
r or that he is exempt hcrefrom and the basis for the alleged exemption.Any violation of
FZa Section 7031.5 by anyapplicam for u lmrmit subjects the applicantmucivil penaltyof OUTLETS-SWITCHES-FIXTURES
f 0 t mom than tine hundred dollars(8500). NEW RESIDENTIAL ELECTR S .FT.
tY n❑ hasownernpheproperry.ermyemployecswithwages avhevsolecompcnsation, Q STORIES TYPE CONSTRUCTION
y will do the work,tndthe stmeturcis not intemdedoreffcTW formle(See.'l044,Business
and Professions Colic: The Contractor's License Low does not apply to an owner of I '
property who builds orimproves disman.and who does such work himself or through his
employees,provided that such ent is sold
within
it arenet intendedproffetied forsale.If,
OCC.GROUP RES.UNITS
however,erwill have
[lit ur improvement ishat]to di inone t build or improve for the
urpose f TOTAL:
builder will hove We burden of proving that be did not build or improve lis purpose of /
vele.).
❑ I,asawnnranhe propeny,am ucwsivayamtracting with licenxer conwcmrsm QTY. PLUNKING PERMIT FEE FLOOD CONE. APN
conswct the project(Sec.7044,Business and Professions Code:)The Contractors
License Liwdocs not apply to sainvon ffiropety who huilds or impowesthermm,ml PERMI"T ISSUANCE
whocontracts forsuch projects with a comractor(s)licensed pumumtto the Contractora ALTER-URAL VF 'TER EA
License Law. - ( 1 FEESUMMARY
❑ I am exempt under Sec. B&P C for this omm r BACK FI PROTECT.DEVICE, OU I,IDE FEE
SANITARY Y N
Owner Data D NS-FLOOR,ROOF,ARI?A,C O. RECEIPT 0
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby affi®that I have a cersificate of consenuo self-insum,or a certificate of RECEIPT#
Workers'Compmention lnsumns,or o cerried copy thermf(Sec.3800,Lab CJ which FIXTURES-PERT R PARK FEE Y N
covers all In,, u l"� GAS-13A.SYST NC.40 LE RECEIPT#
Policyp — v BUILDING DIVISION ITF.S
Company GAS-EA. F. -OVER4(fiA) PLANCHECK MH
eriFed copy is hereby furnished.
Cenilied copy is tiled within,city i.,Puadivision. OREASEfINO TRLW STI+ .RCE 'OR GRAVING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GRE35 It SOILS FEE I
COMPENSATION INSURANCE
phis section need not be completed if Ne permit is for one hundred doll 61(X1)' SEWS ANITpR -STORM HA 0(IFT. ENERGY FEE.
or less.)
I emify tom ante perf...r d Ne work for whichthis perenit is is, ,Ishell AT iA R /F.LIi
not employ any Person in any manner so as to become subject m @c orkere' PAID
z Compennatior-Lawso'Culifomia. Date STHMIRHATINO Unm Receipt If
O Applicant
NOTICE TO APPLICANT:If.after making this C<nificme of Exemption,You should NEW RHgD IAL PLMR. SQ.Fr. TOTAL
!-'t-y become subjecuo(he Workers Compensation provisions oft he labor Coda you must
7 forthwith comply withsuch provisions or this permit shall be deemedrevnked. BUILDING THE
[3I (]
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending ugency for the performance of In
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEL:
Lender's Name
IL
0 F Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U c 1 cenify that 1 have mad this application sad stat,that the shine information is
tired.l agree m comply with all city and county ordinances and state laws relating m TERM I'1' MECHANICAL FEF.
ISSUANCE
�-' buildingcnnnmmion,and hereby emhoriu repmunmUves of this city toenterapon the CONSTRUCTION TAX
L) Z shove-me dammed progeny for inspection puryuses. ALTER OR ADD TO MECH.
Wed agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,cons and expenses which may In any way accrue against said City AIR BAN DLING UN 11(TO 10,000 CPM)
roc ucntt of the granting fit is permit. �/
' Det
7 AIR HANDLING UNIT(OVER 10,"CITM)
Sig at oro Applicum/Comeacter EXHAUST HOOD(W/DUCT)
` PAID
HAZARDOUS MATE.KALS DISCLOS / HEATING UNIT(TO IM."BTU) Data Receipt#
Wil l he applicant or future building nccupam store or handle hazardous material HEATING UNIT(OVER 10(1,(X)BTU) TOTAL: ,
ns Adnal by the Cupertino Municipal Cade,Chapter 9.14,and the IlmdOr anA$alNy
Code,Section 25532(u)? VENTIIA'I]ON FAN(SINGLE RfSID) *' •-"•y+ u
13 Yes 11 No
/ BOILER-COMP CHIP OR 100,0(p BTU) 0 AT'E
Will thouppllcuntarfumre bullJingmcupam ueeupripmcndadcvicG which emit
;nnum mus it emnmminam s as retired by ore Bay Area Air Quality Management
• )kticty BOILER-COMP(UVER 100,000 BTU)
❑Y. ❑No NEW RESIDENTIAL MECH.—SQ.FT. J•T
I have read the hazardous materials rcytimadems under Chapter 6.95 of the CITY OF. CUPERTINO
California Health&Safety Cos,Sections 25505.25533 and 25534. lundersmnd Nat BUILDING DEP.
ifrhebuildingdmsnmmerttn yhaveattn ct Aismyss pomibiliry tonotify the
mupum of the reyuirements which man s and prior m issuance of a Certifieano of
Occupancy. �� t
Owner er umhorized ag<m Dam TOTAL: LSSUI?O BV:
OFFICE