26817APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
PLUMBING -ELEMIMECHANICAL
;{^jRD11.DING PROJECTIDENTIFICATION- -
PERMITNO.
26817
LLIDIN//GG�ADDRESS :
SANIT ftY NO.
APPLICAATTIONSSyUBMITALDATE
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UNITM LOT#
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OWN' SN/AMF.: PHONE:
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ARCHITF.CT/ENGINEFR: LIC NO: DRESS: ST—Qans�J
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-�UICDINC PERMIT INFO- .
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PLUIa1B MECH
PERMIT ISSUANCE
\L�J1R�''
Lek
LICENSEDCONdunder CONTRACTOR'S DECLARATION
I hereby eRmnlhatlem licensed underproviaimsofChapter 9(commrncing with
APPLIANCES -RESIDENTIAL
TOB DESCRIPTION
Section 7000)of Division 3 ofthe Business and Professions Code, and my license is in
full force and a t.
PANELS
License lea Lies LCL-wZQ rn
UPTO200AMPS
Cmtmmm
201 - 1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shall bd used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIALCIRCUIT/MISC.
1 hereby affirm that 1 un exempt from she Concoclo's License law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or cowry
TEMP. METER OR POTS MST.
which requires a permit m comvuct, slur, improve, demMish, or repair my ma.m.
#dor to its issuance,almrc,.a. theapplicant for such Femur to filatidinedsuument
POWER DEVICES
that he is licensed pursuant to the provisions of the Conrracmfs License Law (Chapter
9(commmaing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or thin he is exempt therefrom and the basis for the alleged exemption. My violation of
Section 7031.5 by any applicwt for a Femur subjects the applicant to a civil pemlty of
OUTLETS -SWITCHES -FIXTURES
not more than five hundred dollars ($500h
❑
wrk,andepropactum wrnifor
NEW RFSIDENTIALELECfR_SQ. FT.
STORIES
TYPE CONSTRUCTION
imy intended oro
o the
will dothework, andtheamcureisnotinullede deforseta(Sec. 7aA. Bulinus
ado(Sa 70,PI.ensiness
and Professions Cale: The Contractor's Licensee Lew does not apply m an owner of
Law
property whobuild,mim on,cithereon,andwbodcesauchwork himselforthrough his
own employces,provided thatsuchimprovemenlsarenotimendedmoffemdforsale. If,
OCC. GROUP
RE.S. UNITS
however, the buildingor improvement is sold within one yearn(completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
sale.).
❑ I, osownerofthepropeny,ameadusivelyconbecting withlicemedconwcNrsu
lux n±p – .•wl
y Ye ser a*M IT(' PE&'n
FLOOD 20NE APN
construct the project (Sao 7(s44, Business and Profeuiam Codd:) The Contraaoh
License Law dors not apply munownernfpropeny wMbuildaorimprova thereon, and
ERMIT ISSUANCE le on
whocontracts mrsuch pmjems with ecmtmcmrts) licensed pursuant a the Con—vu,
License law,
I R P COn1P
FEE SUMMARY
❑ I em exempt wader Sm. , B & P C for Nis reason
cP
wi�AA V E •O�a�
Wee
I
gANITARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION
'oWk 'A ND'
RECEIPT#
SCHOOLTAX YN
❑ thereby affirm that l have a certiEcam ofconsdnno self-insum, m 4cdnifisauofWWI,,RECEIPT#
Workcr%Compensetion Insurance orocesdfiea copy thereof(5x.3800, Lab CJ which
covers all employee's under Nis pemtit.
Policy If
ar,a a S'A C
PARK ME Y N_
RECEIPT 0
BUILDING DIVISION FEES
Company
CICenifiedcopyisherebyfumiNed.
Jr.
Il'
PLANCHECK PEE
GRADING FEE
❑ CmifiM copy it filM with N<city inspaum Nvision. GREASFgNDUS
CERTIFICATE OF EXEMPTION FROM WORKERS'
ILS
COMPENSATION INSURANCE
Max section mordant he completed ifthe Femur is foronehunduddollan(SIM) SEWER -SANITARY EA. 200FEE
or less.)
I certify that in Ne petformsnce of Ne work fm which iMs permit is iuuM, I shah ECI'R 11
not employ any person in my mummer so u to become subject to the Workvi
PAID
Compensationlawsof Califamia. Dau
WA 0.SY5 LDate
Receipt#
Applicant
NOTICE TO APPLICANT'. If. after making this Certificate of Esemption, you abroad
PLMB ij SQ. FT.
TOTAL:
become subject to to Worker's Compensation provisions of the Labor Code, you roust
fanhwith comply with such provisions or this Permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC PEE
Lender's Name
✓p7�y
Landds Address
Q 7 21 CHANICAL PERMIT FEE -
PLUMBING FEE
1 certify that 1 have read this applicafion and state that the above informations
torten. l agree to comply with all city and county onfinances and sue laws mlalingN
ISSUANCE
MECHANICAL FEE
building conamuction, and hereby aathorize upmunudi eaaf thisciry u rnterupon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and kap harmless the City of Cupertino against
limilitmajudgmenu,coats andexpenseawhich may in my way acameagainst said City
AIR HANDLING UNIT(TO 10,000 CFM)
into nee ofN ting of Nis permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
PAID
igm um of Applicm o minor I Data EXHAUST DOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
I MATING UNIT (TO I W,0(1(1 BTU)
Data Receipt#
TOTAL:
doas etmN
Will the applicant or future occupant sum or handle hawm
az defined by the Cupertinon Municipal Cade, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100.1100 BTU)
Cede, Section 25532(a)7
11 Yee 11 No
VENTILATION FAN (SINGLE. RE81D)
ISSUANCE DATE
Will the opplicmt or future building occupant use equipment ordevices which emit
BOILER-COMP(3HPOR 100,031 BTU)
huzardoaa air ctimaninmm as defined by the Bay Arca Air Quality Management
Dunictl
BOILER - COMP(OVER IW.WO BTU)
❑Yee El No
1 have read the hazardous materials requirements under Chapter 6.95 of the
NEW RESIDENTIAL MECH. SQ. FT.
p
Y
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understood that
if the building does not currently have a mount, that it is my responsibility to notify the
occupant of the mquGements which must be met prior to issuance of a Certificate of
_
U(G n _
AUG
Occupancy.
/ F'
ISSUED/8V: u
Owner or amhmized a gent Data TOTAL:
OFFICE "'r#d