26740 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLEC1'RI.Ai. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26740
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
V\ (UNff# LOT# 7— —
TA
C
OWNF SNS[;: as
NTRAUTOR'SNAME: LICNO: 111 l
a aD 2 pLV N/C CONTR .#
•a,RCIIITECT/ENGINEER: LIC NO. A DRESS: {'1/1 e SV NN lll�
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE. BUILDING PERMIT INFO
RLDG ELECT PLUMB MECU
PERMI'FISSUANCE - ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTIONyz I hereby affirm that l um licensed underprovisionsofChapter9(commencing with
00 Section 0000)of Division 3 ofthe Businessand Professions Cale,and my license is in PANELS
NLfull lorce anJ
Q- Liana Class �+ Lic.M UP T02(q AMPS r, {zr�p
6y Ila¢ Comreaor 261-1IXp AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ. .FLOOR AREA S/SQ.IcI'.
OZ—M lundcrsmnd my phnnx shall be mal us puM1liu rcwr ds.
SIGNS ELECTRICAL
qY�.4 Licensed Profcasional
Sas�y Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/Misc.
W SON 1 hereby n.(Se than I xm exempt from the ContractorssCex License Law for the is^. s. a..� IN ra �-
G I'allowing meum.(Seclinn9W LS,Busincae unJ Pfnl'eseions CnJe:Any city nr county TEMI'.METER OR POLE INS"1'. Ill IIJ' 1p'.'dl; N
t�a7 which it,iwexaperms revolves
he
al,fi.Tmpmve,h .ith.mmpairanyawment '
K ¢0 pdmrmitsisimsed pursuant
tit to the
tpr visio sof the Co pertniuo Glcnse La statement POWER DEVICES /
y4 cOO thm he is licensed pursuant.the provisions of the Contractors License Lew(Chapter 0, P ^
subjects the applicant 1)(commencin mSec0on 9000)of Div ision 3 of the Business and Prnfesxlons Code SWI MMING POOL ELECT RIC
t Zo (commencing ) V hUAT ON
Q .that he is exempt therefrom and the basis for the alleged exemption.Any violation of oTnusrs-swlTexps-mxTUREs DATE / g
Section 7031.5 by any applicant for a permit tto a civil penalty of
Ontit wereman live hundred dol lar,($500). -
❑ I,asowncndtM1eprnperty,army nnployecswith wages nsthciraaecompenmtion, NEWRESIDENTIALELECIR _SQ. - STORIES TYPECONSTRUCTION
a 3.- will dome work,and the stratum is not iateralMorowoxi forade(Sce.]0,L Business
and Professions Cade:The Contractors License Law does not apply to an owner of
prolxny,who builds.,improves thereon,and why does mch work himself.through his
own employees,provided that such improvememsarc not intended moffered forsale If, OCC.GROUP RIS.UNITS
however,tlm building or improvement Is sold within one yearnfenmplGim,the owner .I.O,TAI.
builderwill have the burden ofproving that he did not build or improve forpmp.0 of
sale.).
❑ mtrs
I,as owner ofthe property,aenclusivelycontraciing with licensed conacrom QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
instruct the pmject(S .9194,Business and Professions G.Ic)The Contractor's
Lec
icense Law doexam apply to an ownerofpmpeny who buildsorimproves thereon,and PERMIT'ISSUANCE '1 •p�
who contracts forsuch projects with acommctons)licensed pursuanuothe Comractors AI TIiR,DRAIN&VENT-WATER `s- FEG SUMMARY
License Law. (EA)
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PRO'I ECT.DEVICEOUTSI)I: PS
SANITARY Y_N
Owner Data RECF.11'Tq
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL'TAX YN
❑ Thereby MGrm thud have ecenifcmc of consenuo self-insure,o,aceni0cate of FIXTURES-PER TRAP ,�....//II REcizurf#
Workers'Compensation Insmmnceor u certified copy thereof(SeC.3g66,Lnb CJ which 3-Z- PARK PEE Y N_
covers allean'I a ticrtlkspemsik� ^ GAS-EA.SYSTEM-I INC.4OUTLETS RI!CEB'T#
Policy# ��JJ AA„ 11 VViicc!! BUILDING DIVISION FEES
C.ntpamY ��.1 '
Certified copy isb chyyf mishuL I GAS-EA gY59'EM-OVER 4(P,A) PLANCIiP.CK FEE
❑ Cenilied copy is 0lcJ with the city inspection division. GREAS114NDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE CRAP SOILS ITE
COMPENSATION INSURANCE
('This section need not be completed lime permit is forone hundred dollars($100) SEWER-SANITARY-STORM HA.YOIIPC ENERGY FEE
orw of
I certify that in the penformence of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELF.CIR
not employ tiny person in any manna so as m become subject to the Work.' PAID
Co..tKm.dm Lawsof Culifomia. Date WA'I'ER SYSTRIOUREATINI Ohm Receipt#
0 z Applicant
z Q NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you should NEW RMID12MIAL PLMB. SQ.FT. TOTAL:
f0, become subject to the Worker's Compensation provisions of the labor Code,you must
mnhwal,amply with such provisions or this Permit shall be deemed revoked, BUIIAL NO FEE
0. (� CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
I hereby affirm that is a construction lending agency for Ne performance of TOTAL: ELECTRIC FEF.
U O rho work for which this permit is issued(Sec.3W7.Civ.CJ ..�
Lender's Name
00 U lenders Address QJ'Y. MECIIANICALPERMIT FEE PLUMBING FEE
1 certify that 1 have mad this application and state mat the above information is
correct. I agree to comply with all city and county ordinances and amm Taws relmingto PERMIT ISSUANCE MECLIANICALFEE
�^ building construction.and hereby authorize representatives of thiscity mentor upon theCONS'TRUCTION'I'AX
V Z alawe-mentioned progeny for inspection purposes. ALTER OR ADD TO MECI I.
(We)n rce I save,indemnify end kap hemtleas the City of Cupertino against
Iiuhlites,' Jgmenes.costs and expenses which may in any way accrue againstwid City AIR HANDLING UNIT(TO I(LI100 CFM)
arc ore enew ol'me gnamin,of IN,permit.
I /Y AIR HANDLING UNIT(OVER 10,000 CPM)
S i gliaMeof Applican tractor Da EXHAUSTHOOD(W/DUCT, PAID
HAZARDOUS MATERIALS DISCLOSURE HP.A9'ING ON IP ITO 10L,,,BTU) Dtim Receipt
Will the applicant or future building occupant store or handle hazardous material
as defined by the Calendar,Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: 4
Cade,Section 25532(e71
1:1 Yee 11 No VEND LATION PAN(SINGLE RFSID)
Will theupplicanlnr(more buildingcecupanmmeyvipmem BOILER-COMP(3HP OR 100,(1(10 BTU) ISSUANCE DATE ordevices which emit s� ��pp �p
Eard.ms air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) • .W l v
Olxtdcf? QQpE
❑Yes ❑No NEW RESIDENTIAL.MECIL SQ.FT. JUL 14 cos+
I have rend the hazardous materials 5505,25533 under Chapter ersi .f the
California Ileul:h&Salety Cade.Sections 35505,2553]and 255]4. I undermunA that
if the.:d does near have a mount.that it is my responsibility to notify the CiIIY V- VWrCniou
well rot the iremn the met prior to issuance of Cenifiwl of
`1-IgAeNf
Owns tumonrizedagc" ate,/ TOTAL: ISSUED BY:
OFFICE