26182 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO rujIllutivio-h.LLCI RICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MRCHANICAL 2618 eI O
HUIIAING DIVISION BUILUINGPROJEC'I'IUEN'I'1FICATION' G 10
B ILDING
I ' IOADIG6_DRrIriSrS:�
SANITARY NO. APPLICATION
�ISUBMITTAL
DAIL
SierSTvw LOT N
OWN SNAMF: RASNAME LIC NO: ,p
NIC CONTROLa
ARCH]TF.CT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE HUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAh El 'tjL El El
I hereby affirm that l am licensed under p (commencing JOB DESCRIPTION
❑02 Ya prd Professions
and my liven with
oe00 geetion force and effect. J.f the Business and ltofessions Code.erM my license is in PANELS
Fjoe<,, full nsClas ef(eet. ('� FIR /tea
ly License Closs Co.N UP T0200AMPS , ■W�`ly
Date Compactor 201-1000 AMPS
FNZ ARCHITECTS DECLARATION FL RN E/SQ.14.
OZ—Q Iundcmandm 1 OVER IIXp AMPS (� 1 I J
OZ�p YPam shall be usedn Public records. �, '��
r4tb SIGNS ELECTRICAL
y j Licensed Professional II
KWF 3LLOuNy,y
OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC.
Ib, affinan,cbythin 1 an exempt fromthe CiarmiLicense taw forMe ; Fj`
following reason.(Se Business and Profession,Coe:Any city or county TEMP.METER OR POLE INSf.O; which rtyuirts a p(rein 10 consumer, improve,demolish,or rapar `)
u
any awcturc
prionoils issuancc,a6o requires the npplicanl forsuchpelmilm fileasigntsimmemem POWER DEVICES
that he is licamodpursunnno the provisions of the Contrucm's License law(Chapter
aaoM 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Rxjrose or hat he is exempt therefrom and the basis for the alleged exemption.Any violation of OWLETS-SWITCIiPS-
F-Z¢ Section 7031.5 by any applicant In,aremlitsubjeas the applicant to o civil penalty of FIXTURES
�Sp rt than five hundred do'ko,($Sol). NEWRESIDFNUALELECIR _SQ.FT.
�Ff 1,asowneroflhepropmy.ormyemployceswithwagcsntheirsole<ompenmion, STORIES TYPF.CONSTRUCTIOP
a3
— 'wit work,and The structure is not intended or offered for sale(Sec. B usiness
and Profusion Code:The Contrecmds License Law does not apply to an owner of
property who builds or improves thereon.and who does such work himself.,through his
on employees.provided thmxrc no
uchimpmvementsalintconferred ofed forsale.if, OCC.GROUP RES.UNITti
however,the building or improvement is sold within one yearofcompletion,the owner-
builder will have the burden of proving that be did not build or improve for purpose of
uleJ.
❑ Las owner.fthe property,am exclusively contracting with Beamtmrs
Beamed conemto QTY. PLUMBING PERMIT FEE ILOOII"LONE APN
construct the project(Sec.](W4,Business and Professions Code:)The Contractors
License Lawdocs not applyto anownerofpropcny whobuildsmimproves thereon,vtd PERMIT ISSUANCE
who contracts for such projects with aermm etor(s)licensed punsaaouo the Conlracmrs
License Law. ALTER-DRAIN&VE JT-WATER(HA) FEE SUMMARY
❑ I am exemplunder See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date SANITARY YN
DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
❑ Thereby affi,m that l haveacenificateadornent toxl6ins......certificate of IIXTLRES-PER TRAP RECEIPT#
n'
WorkcCompensation lnmmnceor a certified copy tbemof(Sm 390).Lab C.)which PARK FEEyminN_
rs all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA)
❑ Certified copy is hereby famished. PLANCIiGCK FEE
❑ Certified copy is Bled with the city inspection division. =H�TER
TRL WASM
ADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ILS FEE
COMPENSATION INSURANCE
(This union need not he completed Hire Permit is foronehundred dollars($100) ARY-STERGY FEE
less.)
I cmify that in the performance oflhe work for which this permit is issued.)shall R W/VENTnot employ sty person in any manner so as to become subject t.the WorkersDCompensatiouLawsofCalifomia. Date NIGREATIDam Receipt#z N(TAppIicant ICE'10 APPLICANT:If.after making this Certificate of Exemption,you should TIAL ELMrLObecome subjectto me Worker's Compensation Provision of the Labor Code,you mustTOTAL:
a > fonbwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC IEE
Z) Z Ihereby affirm that then is a convection lending agency for the performance of
U O the work fur whichthis permitls issued(Sen.3097,Civ.C.) TOTAL: ELECTR IC FEE
Lenders Name
U.
V Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
[Ja 1 cmify that I have read this application and stem that the above information is
F-' W rcct. l agree to comply with all city and county ordinances and state laws relatinglo PERMIT ISSUANCE MECHANICAL FEE
_ V) building convection,and hereby mumodxe repsesenmtivesofthis city to enter upon the
UZ above-mentioned property for inspection WToses. ALTER OR ADD TO MECH, CONSTRUCTION TAX
�-' (Wc)nrce to save,indemnify and keep M1arn a the City of Cupmino against
liabilities or an smsN.adi,x sc,whih nanaccrue against accragainst said City AIR HANDLING UNIT(TO 10,000 CFM)
I.on tre c the a is pc
AIR HANDLING UNIT(OVER 10,000 CFM)
Signslare of ApplicanUCen a De EXHAUST HOOD(W/UUCT)
PAID
HAZAR US MAIERTALS DISCLOSURE HEATING UNl'T'(TO 100I00J BTU) Dam Receipt#
Will the applicant or future building moupant store or handle baysrdous material
as defined by the Cupenium Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T L:
CMe,Section 25532(.)?
❑Yes ❑N. VENTILATION FAN(SINGLE RTSID)
BOILER-COMP(3HP OR 100,f l BTU ISSUANCE DATE
Will Ihevpplicamnrfutumbuilding.ccupanlumequipment ordevices which emit )
hazardous air contaminants as defined by the Bay Area Air Quality Management =MHCO_
District? P A
❑Yes ❑No T.I have rental the rotunda.,materials requirtm rds under Chapmr 6.95 of thejf/j r.�Cdifomialicalth&SafayCWI.S.Ii.ns25505.25533and255M.lundmaandlhin 'If,H FY1994
aupant Of the requirements which must IN,met prior to Issuance of a Cerarcam ofZs/'rOccupancy. V `rOwncroraulbonzedari DamL: ISSUEDBY: rV IIYf�C II�
OFFICE