26556 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 ILVI .-LLL. RI AL PERMITNO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL (JCC `Q
BUILDING PROJECT IDENTIFICATION G o J J v
B UILDING ADDRESS: SANITARY NO, APPLICATION SUBMITI'ALDATC
IeI
1 1& V r` UNIT LOT
OWIN AME: PHONE: CONTRA 'OR'S NAME: LICN NUC CONTROLM
r I,0 RobtLLTt&-VC L
.ARCHITUCTIENGINHER: LIC NO: ADDREg ' ❑
%5 CTEZ
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
HLPG ELECT PLUMB MECH
PERMIT ISSUANCE.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB D 'CRIPTION
W0042 Ihereby affirm that l am licensedumlerprovisionandChapter9(commenciagwith
F 00 Section?0001 of Division 3 of the Business and Profession$Code,scout my license is in PANELS
W d Efull force reit effect.
Zly License Class _ Lic.p (�09'1� / UP TO 200 AMPSAyp
ob Date Contractor 201-10130 AMPS
ZOr`nisZ ARCHITECTS DECLARATION OVER IOW AMPS SQ.�RAREA $/SQ.FT.
OZ-0 I°"wand my Warr shalt sed us ublic'QoNs.
F,y-f+I _(fa'(a•�VR—\_` �✓ SIGNS ELECIRICAI. �� �
Q Licam Pnt essron 11
ecJ OWNER BUILDER DECLARATION SPECIALCIRCUIT/MISC.
°�OIyU 1 hereby affirm that 1 nm exempt from the Cturnmemr's License Law far the
W3 is-r~aii following reason.(Section 7031s,Business and Pmfeasioru Core:Any city or county TEMP.MISTER OR POLE INST.
u'0 J which requites a permit to construct.after,improve,demolish,or repair any structure
}� prior m its also mi the aplicant pfmmch permit m Man signedsutement POWER DEVICES
ac p p that he is licensed pursuant m the provisions of the Communes License Law(Chapter
o. e� 9(can mcncimg with Section 9000)of Division 3 of the Businessand Professions Core) SWIMMING POOL ELECTRIC VALUUA�TIO
=Q orpast hcisex by therefrom mf ra basis fonhenseged exemption.Any violation of OUTLETS-SWITCI IES
Z} Section than by anydreddamforepermit subjectsthe apPlicam toncivil penalty of �C V
not more then Eve hundred dollars(5500). NEW RESIDENTIAL ELECTR _SQ.FT.
'gym ❑ othe wrk.anhepropeny,ermyemployedi or offered
for sale(Sm.
70mpemmion, STORIES TYPE CONSTNUCTION
a3� will dothewonsCdthe structureComisnots Licari ofwdoes not
to 70414,Business
of
and Professions lit Me:The Cnmrereon,1-seems Low such
or apply to an owner of
property who buildsorimpmvicelhereon,and wbr does auchwork himselfur through his OCC.GROUP RES.UNITS
how a er.th eee,provided mat each improvements in one
year o coo pletio ,for sale.owner.
howeer will ave t n burden ovemem is hat he didm one yam of c prove for perthe seof T
builder will have the burden of proving that he did not build or improve for purpose of .
sate.>.
E] 1,as ownerofthe property,am exclusivelycommcting with licenecdcommctars m QTY. PLUMBING PERMIT FEE FLOOD LONE APN
consumer the project(Sec.7044,Business and Professions Code:)The Contractor's
License law dues not apply to unownerofproperty whobuildsor lmprovesthereon,and PERMIT ISSUANCE
who contracts her such projects with acumracturW licensed pursuant tothe Contmetors
License Law. AMER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I vn exempt under Sec. ,B&P C for Ibis meson IACs u OUT �.ES
SANITARY Y N
Owner Date T RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAT , 60Rr�OOPA q,2ND. -� SCHOOLTAX Y N
❑ I herebyeffirm that l have a certificate m(consem m self-incere,or a certificate of - RECEIPT
FlXT'UR -PERTRAN
Workers'Compensation lnsurmce oracenifed copythrnmf(S¢JA00.Lab CJ which nn PARK FEE Y N
covers ell employee's umler this pemdt. AS-EA[�}'fya-1 INCARFCHIPT N
Policy p /-BUILDING DIVISION FEES
Company GAS-EA,SYSTEM-OVER4 CA 7 PLANCHHC FEE .�
❑ CenificA copy is hereby famished.
❑ Ccttifed copy is filed with the city inspection division. GREASFJINDUSTRL WASTE IN`ERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRAP S011S me
COMPHNSAUON INSURANCE
Tfhis section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY.STORM EA.2001T. ENERGY FEE
or less)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENTIELECTR
not employ my person in any meaner so as to became subject to Ne Workers PAID
,z Compensation Lawsof Califnmia. Dau WATER SYSTEMRRHATING Receiptp
Applicant
zC NOTICE IO APPLICANT:IL,after making this Cmtificme of Exemption.you should NEW RESIDENTIAL PI,MB. SQ FT TOTAL:
E-' h hecomesubjem m the Weaker Compensation provisions it labor,Code.you must
forthwith comply with such provisions or this permit shall be domed revoked. I C �—
z CONSTRUCf10N LENDING AGENCY SEIS
1 hereby affirm that them is a construction lending agency for the performance of
ed(Sec,309?,Civ.C.) TOTAL: ELECTRIC FER
U the work for which this Q permst is issued 1
C2. Lender's Name PLUMBING FEE
O U Lenders Address QTY. MECHANICAL PERMIT FEE
1 certify that 1 have mad this application and Stam that Ne above information is
r1' 0. correct.Ingrcemcomplywithalleitynndcounty ordinances and sure lawsreland,to PERMITISSUANCH MECHANICAL FEE
[�^ y building construction,and hereby amborive representatives of this city to enter upon the CONSTRUCTION TAX
U 7 above-mmlumed propeny for inspection purposes. ALTER OR ADD'I'0 MECI I.
(We7 a c m save, emnify and keep harmless the City o Vd'
atIiabilitics,ju gr ents,coat daumcswhich n in my ay cm g AIR HANDLING UNIT(TO 10,1300 CPM)
c n'e ftheg t sgofddxMoi. AIR HANDLING UNIT(OVER IU,gp CPM)
nature of r0md/Co eem P.%I IAUST HOOD(WMUCT)
rn1D
HAZARDOUS M yRIAIS DISCLOSURE s HEATING UNIT(TO 100,000 BTU) Date Raarid#
W ill the applicant m future building attupeat pore or handle Wardens material
n$defined by the Cupertino Municipal Cole,Chapter 9.12,and the lfeafth and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cole.Section 25532(ep
El Yes 1:1 No I VENI'ILAT10NFAN(SINGLERESID)
BOILER-COMP(JI IP OR 1 W,fl(10 PTU)
ISSUANCE DATE
Will ad,co icaninr ds as building by the ay Area it orality Ma agree it f� �2
ha'grdous ser contmninenn m defmrd by the Bey Area Au Quality Manngemenl BOILER-COMP(OVER 100,000 BTU) 1r A Q
District?
❑Yes ❑No NEW RESIDENTIAL.MECII. SQ.FT. JUL u ���
I have teed the hnamlum materials reyuiremsom under Chapter 6.95 of the
Celifomiu 11eailh&Safety Core,Satimm 25505,25533 and 25534. I understmd that
if the building docs nm currently have a tenant,that it is my responsibility to notify the ysTy�
mcep rm of the requirements which must be met prior to issuance of a Cenificme of C f I Ur uurt/I I IjV(
Occupancy.
Ownerortatelm od agent Dare TOTAL: ISSUED BY:
OFFICE