26224 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-LLECJ RIAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�
HU"DING DIVISION IIUILDING PROJECT IDENTIFICATION 4
BUILDI/NU AUDRF.SS: SANITARY NO. APPLICATIONSUBMHTALDATE
• { /sem•^ �L • `r r UNITp LOT r �.g
OWNERS NAM P NE: CONTRACTOR'S NAME: LIC NO:
O� e N/C CONTROL p
\RCHIIL /nNG EER: LIC NO: ADD S: ❑
CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
c` ELECT PLUMB MECH
(�s� PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _dt
satRAW
C
qmZ Ihtteby affirm that lam licensed underprovisionsof Chepmr9(commencing with s',TI`+W'4
XUU00 Section]000)of DivisionJO(Ne Business and Professions Code,and my license is in PANEL
S
full force end effuL
1<-,Zm License Class Lic.g UP T0200 AMPS
m1-<y Dam Comra<mr 201-1!100 AMPS
ZOyZ ARCHITECTS DECLARATION OVER IOW AMPS SQ.Ff.FLUOR AREA S/SQ.FT.
O Z II understand my plans shall be used us public records.
SIGNS ELECTRICAL
Licensed Professional
9yrd OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
xdxOaF I hereby alBmr that 1 am exempt Dom the Commctors license law for the
W 3 pm following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
m which requires
res a permit to construct.alter, pai
er,improve,demolish,or minor any structure
i� prove m ds issuance,also fequires the applicant forsuch permit file asignedsutement POWER DEVICES
that he is licensed pursuanto the provisions of the Contractor's License Law(Chapter
do 9(cmmm mg with Section 700(fif Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VA(^.(�pTION
or thus he isexempt themfrom and the budis forthe alleged exemption Any violation of OIITLEIS-SWITCHES-FlXTURES �OOd -%1--
-0".
1
Sectio us031^eby mY epPlicnm forapermit subjects N<epplicmnovcivil perWryof
q t sown rofthe dopmy,dollors yempl NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCfION
roflhepropeny,ormy employaswith wages as tM1eirsmlecompemauon,
will do work.and the strudureis notimenJMor OffereJ fnr¢ele(See.]1144,Business
and Pfofes'ons Code:Ile Contractors License Low does not apply to un owner of
property whobuildsorimproves therevnand whodoes such work Nmulforthmugh his OCC.GROUP RES.UNITS
wnemployecs,providedthnsuchimpmvemenuaeamintendedoroffered foreale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of that he did not build or improve f TOT L:
proving Prov purposeo
ole.).
i ❑ I,azownttofthepmperty,ameadusivelycantmcting withliumedconnvcmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7(4q Business and Professions Code:)The Communes
License Law does not apply to an ownerofpfoperty who builds or improves thereon,and PERMIT ISSUANCE
whocommew forsuch projects with acontructorod licensed pursuanno the Contractor's
License Law. ALTER-DRAIN&VEN'T-WATER(EA) FEE SUMMARY
❑ I oro exempt under Su. ,B&P C for this reason OUTSIDE FEES
BACK giNPROTECT.pI, AR Y N
Owner LF
Dae DRAINS-FLOOR,ROOF.AREA, OND.! C R[CFIPI'#
WORKMAN COMPENSATION DECLARATION 30LTAX` IRECLIPI'M N
❑ I berebyuffirm tha l have a ceni0cate ofconsenun self-insure,or a certificare of (. ,I T
FlXTURM-PER TRAP \d
comkers Coml¢nutionher this rme out. ifedcoPY thereof(gee.3800.Lab C.)which P K Y N
covers allemployee's under this pemrif GAS-FA.SYSTEM-1 INC. OUTLEfS RECEIPT#
Policyp BUILD GDIVISION FE 00
Company GAS-EA.SYSTEM-OVER E
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEC
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not be completed ifihe permit is for one hundred dollars SUN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees)
I certify that in the perfomunecd the work for whichddu permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in my summer so az to become subject to the Workers' PAID
Corn,maation Lawsof Califemia. Date WATER SYSTEMOIRLATING Dne Receipt III
O Z Applicant
z7�+ � NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL,
t" ti become subject o the Workers Compensation provisiom of the labor Code,you must v
tofoMw!to comply with such provisions or this ponnitshaill be deemed evoked. BUILDWG FEE ICA s—a
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thatthem is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3W7,Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name�
U PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 certify,that 1 have sad this application and.,,,he,the above information is
6i correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
to building construction,and hereby aitheriu epresentetives ofthis city to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree sant,indemnify and kap hamdess the City of Cupertino against
liabiliti dgm costs xpmues which mayin my wayec. ageimt aid Ci AIR HANDLINGUNIT(TO ULMOCFM)
note egret (this pe
AIR HANDLING UNIT(OVER III"CFM)
Silmame of Ap t rmrutor D EXHAUST HOOD(WMUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(To 100,000 BTU) Data Receipt#
Will the the Cuprs,or ertino umbuilal Code,
Clo tame2,handland
eHealth and Safety HEATING UNIT(OVER IW,WO BTU)
al
az defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will the applicant nrfuture building oecupmuse cantonment nrdevices which emit BORER-COMP(3HP OR IW.OW BTU)
hessrdous air contaminmes az defined by the Bay Area Air Quality Management BOILER-COME(OVER 100000 BTU)
imia]
. ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT. #�
1 have mad the harardous materials mqutremi n s under Chapter 6.95 of Ne APR
California health&Safety Cade,S«tions 25505,25533 and 25534. 1 understand that /I ���
if the building does notcurrently have a tenant,that it is my respomibilay to notify the wa, /f
mcupant of the requirements which must be mel prior to issuance of a Cenificate of Y Y
Occupancy. (!"
Onoic'muutheiired agent Data TOTAL: ISSUED BY:
OFFICE