26135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO11 UB..ING-EEELT'RICFL PLRMl['NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL fJ[v a �� C
BUILDING DIVISION BUILDING PROJECT IDENG'I'IIrICATION J
BUILDING ADDRESS: yp�7 y. {������/�r� ��//��y/sf� SANITARY NO. APPLICATION SUBMITTAL DATE
O�s+ -wp \ gzes,1NITp LOT
O ERS NA I?: P ION CO ACfOR'S NAME: L C NO: N/C CONTROL p
rV1 (? 3 0
CUITI:T/ENGINEER: LIC NO: ADDRESS:ivo— Vk_ ❑
-ONTACT: PHONE:
. QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
BLDG ELECTMECH
PERMIT ISSUANCE 1:1P MB 1]
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL fOBDESCRIPfION
rawz Ihereby affirm]hat I am licenudunderpmvisionsofaripterr)conamencingivith
yy y00C 000
Section 7 ).(Division 3ofthe Business and Professions Code,and my lice.is in PANELS
F zzW Lclenu Claueffe Sl Lie.. S' !to I UPT02MAMPS /
m=y Dam Comrucmr 201-IOW AMPS SQ.IT.FLOOR ARCA $/SQ.FT.
zO,z ARCHITF.CI'SD. TIO OVER1000AMPS
O Z o'— I understand my plans shall be used as public ancrods. 1�
�y W SIGNS ELECTRICAL t ID - �,lg p
CWG Licensed Professional OWNER-BUILOER DECLARATION SPECIAL CIRCUIT/MISC. s �'I u�'
3LLF' 1 hereby affirm that I and exempt from the Connac]ols License,Law for The I�
F 0 m following mason.(Sibs on 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a pc]mi]to construct,alter,improve,demolish,or repair any structure
�Y prior to its Issuance,also requires the applicant forsuch permit o File&signed suamment POWER DEVICES
y(E140 that he is licensed pursuant o the provisions of the Communes Licenu Law(Chapter
n. oK 9(commencing with Sateen 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC � VALUtWON
or that he is exempt therefrom and the basis for the alleged exemption.Any violmiorof OUTLBfg-SWITCHES-FIXTURES
I:za Section 7031.5 by any optional for a permapplicant it subjects the applicano a civil penalty of
g C not mom than five hundred dollars(SSW). NEW RCSIOENTIAL ELECTR S .PT.
K $ El1,asownerafthepropeny,urmyemployuswith wages astheiraolecompensetion, _SQ.FT. TYPECONSTRUC`HON
W will do the work,and]hesuucturcis not mendedoroffered forsale(Sec.00144,Business
and Professions Crile:The Contmcmes License law does not apply to an owner of
propcny who builds orimproves thereon.and shrides s each workhimulforthroughhit
awnemployes,pmvidrr ]hetsuch mpaovemwi]sarene imendedmoffered fur owner.
OCC GROUP RCS.UNITS
however,the have
the errden of poising
is sold within one year or mprove for
the owner-
huildcr will huvethe harden of proving that he did not build or improve fa purpose of TOTAL:
sale.).
❑ I,asowneroftbe property,amexclusively contracting with licensed contractors to QTY. PLOMBINGPERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions CWa:)The Cono-anoee
License Lawdnesnotapply torn ownernfpropcny whobuilds orimproves thereon,and PERMIT ISSUANCE
whocontransforsuch projects with accommcmr(s)licensed pursuant mthe Contractor's
Lt.Law. ALTER (CA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,R @ P C for this reason BACK FLOW PROTECT.DEVICE OUTSma FEES
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOI',AREA,COND. RECEIPT.
r WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm that l have a cenificam ofconsent to self-insum,or a cenifcute of FIXTURES-PERTRAP RECEIFI'p
Worker Compensutionlnsumnceoracenifiedcapythereof(gm.38W,Leb CJwhich PARK THE Y N
covers rill employees under this permit. GAS-EA.SYSTEM.I INCA OUTLET'S RECEIPT.
Policy. BUILDING DIVISION FEES
Cmnpuny GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cari fled copy is hereby famished.
IV Caddied copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPPNSATION INSURANCE
(This sectionneed not bemmplered ifimpermi]is for hundred dollars(SIM) SEWER-SANITARY-ST ORM EA,2001of. ENERGY ME
or Ian.)
Icertify the in the performance of the work for which this permit is board.)shall WATER HEATER W/VENT/ELECfR Ll I
no]employ ray perm. in any manner ad m]r hecomte mbjcc] to the Worker PAID
Z
Compensation Lewsof Celifomia. Dam WATER SYSI EMITREA'TING Date Receipt.
0
Applicant
zQ NOTICE'1'O APPLICANT:If,after making this Cenificmv of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL,
Navarra subject In the Worker's Compensation provisions of the labor Code,you must
7 fo.hwith comply with such provisions or this permit shell be diamond invoked. BUILDING TEF.
131 ^ SEISMIC FEE
sv CO NST RUGTIONLENDING AGENCY
1 handy that]here is a construction lending agency for Ne perfonnence of
U
V the workfor whichhick this permit is issued(Ser.3097,Civ.CJ 144 ELECTRIC FEF.
Leardees Name PLUMBING ME .�
p U Lara is Address QTY. MECHANICAL PERMIT FEE
I cerify that 1 have read this apPlicatinn end ante the]the above information is
L1a cora], lugree to comply with ell city erW county ordismnm end smote laws relining to PERMIT ISSUANCE MECHANICAL FEE
ybuilding construction,and hereby authmimaprucntafivev ofthia city bender upon the CONSTRUCTION TAX
V 7 above-marrouW pmpeny for inspection Parisians, ALTHR OR ADD TO MECH.
•7 (We)agree to save,indemnify and keep hurmless the City of Cupertino against
liabilitics.judgments,casts and espenus which may in any way seems against said City AIR I IANDLING UNIT(TO 10.00 CFM)
in consequence o�f/tLh�eygmmingof permit. _ / / AIR HANDLING UNIT(OVER I)t]WCFM)
°b�licanl/Cuntmuar� �--�' •-� &f3-m fir/ EXHAuSTHOOD(W/DUC17
Sig aV/2 PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITGO 100,000 BTIH Data Reeeiprp
Will]he in,licw.or(wort building occupant loan or handle hurnrdaus..,ad.) HEATING UNIT(OVER IW,(NIO BTU) OTAL:
as defined by the Conciliar,Municipal Code,Chapter 9,12,and the Health and Safety
Coda Section Yu ❑No 3 25532(x)?
❑ VENTILATION PAN(SINGLE RPSID) col
BOILER-COMP(311P OR IMM,BTU) P dSSIVE DATE
Will theapplicanmr(uwre M1uiidingoccupanmucquipmemordeviceswhich emit h' ,W Y LI'
orVa.s air canmminanis&s defined by the Bay Ams Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disco"' ❑ MAR 111994
Yev ❑Nu NEW RCSIDF3NTIAI.MCCII. SQ.Ff.
1 have mad the hazardous materials requirements under Chapter 6.95 of the
C.liftunia health @ Safety Cade,Setons 2 505,M533 and 25534. I undernund that CI I Y Ur wren I uvU
TV the building does not currently have a tenant,that it is my respomibility to notify the
occupant of the requirements which must he mer prior to issuance of a Cerifica]e of _
Occupancy.
Owner or mahor sed agent Date TOTAL: ISSUED BY:
OFFICE