26928APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OR CUPERTINO
B 1 .DL :-MFCH
PI±RMI'TNO.
APPLICATION/PERMIT
NICAI
PING IFIC
26928
BUILDING DIVISION
BUILDING PR(IJEC'1'IIIEN'I'IN'ICA'1'ION
PRoGcr [BEST
BUILDING A DDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
I`
O O
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\ ` LOT#
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ONTRACfOR'S NAME LIC NO,
N/C
❑
CONIROLN
e 0 � O
C J
C;
ARCHI'ICC1'/ENGINEER: L NO: ADDRESS:
CONTACT; - - PHONE:
QTY.
ELECTRIC PERMIT
PE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT' ISSUANCE
is� E ❑
LICENSED CONTRACTORS DECLARATION
APPLIANCES -RESIDENTIAL
OB DIiSCltll'1'ION
I hereby affirm that l am licensed underprovisiom onChapter!) (commencing with
$action7")of Division 3 ofthe Business and Professions Code, and my license is in PANELS
• full force and effect.
j I.iccrosc Class Lica
UP TO 200 AMPS
.•� hale Contractor
2111 - 1000 AMPS
SQ, Irl'. FLOOR AREA $/SQ. FT.
' ARCHITI=S DECLARATION OVER 1000 AMPS
1 undersmnd my plans shall he nsul as public reunds.
SIGNS ELECTRICAL
i Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUI'1'/MISC.
I hereby afford that I am tempt from the Contactors License law for the
lidlowingreanou.(S,rbam 7031.5, Businessard Professions Code:Anycirynrcmmy
TEMP, METER OR POLE NST.
1 which requires a permit to construct, eller, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit o file a signed statement
POWER DEVICES
j that he is licensed pursuant to the provisions of rhe Contractor's License Law (Chapter
: 9(emencrier, with Section 7000) of Division 3 of the Business and Professions Cade)
SWIMMING POOL ELECTRIC
VALUATION
j order lie is exempt therefrom and the basis for lhcallcgcd exemption. Any violatonof
• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OUTLETS- SWITCIIGS-Ff%TURES
an mora than Eve hundred dollars (Sf ad.
❑ I, asownerophe Property.ormyemployceswihh wegesazhheirsolecomperuation,
NEW RESIDENTIALELECTR_SQ. NT.
STORIES
TYPECONSTRUCTION
will do the work, and the stricture is not intended oroffemd forsale(See. 7044, Business
and Professions Cale: The Contractors License Law does net apply to an owner of
-
propeny whohuildsor improves thereon, and whodoessuch workhlmselforthmughhis
own employees, provided thin such improvements arenm intenJWorofPord foreale.If.
OCC. GROUP
RES. UNITS
however, the buildingoriciprevemern is sold within one yearof completion, hheowner-
builder will have the harden of proving that he did not build or Improve for purpose of
T
sale.).
❑ 1, as owocrofthe property, amexclusivelycontacting with licensed contractors to
QTY.
PLUMBING PERMIT
FEE
FLOOD ZONE
APN
the project (Sec. 70,14, Business and Professions Code:) The Contractor's
Linstruct
icense lawdoes ma.pply m mownero(property who buildsorimprovesthcreon,and
PERMIT ISSUANCE
who commis for such projects with it ontracrods) licensed pursuant to the Contractors
License law.
pLTI±R-DRAIN&VEN'T-WA'PER (KA)
PEE SUMMARY
c❑ 1 vat exempt under Sec. , B & PC for This reason
BACK ROW '13C'ICDLNIO
9'SID1e .F_
Owner Date
�• ' 1 !I
�'
SAN 1'ARY Y N
RECEIPT#
' WORKMAN COMPENSATION DECLARATION
DRAINS -FLO R, BOOP, AREA, CON0.
SCH OL TAX YN
❑ I hereby affirm that l have a cenificate ofcmrsent to sclf-insum, or a maximum of
p1%TLRES-P 'IAAF
RECIiIPTp
PAR FEB Y N
orkcrdCompcnsmlm Insamncoor a moi fled copythereaf(Sce. 3800, Lab C.)whilh - V
covers all employee's ondenbls permit.
GAS-F.A. SYSTH -1 IN OUTLETS �1
RECI±I I'q' b
BUILDING DIVISION LEES
polio#
Y nag
Com
CanS-EPti
❑ Cmifiedcopy is hereby furnished.
GA YSTEM-OVIiR4(
_
CHECK FEE
❑ Cutifiul ropy is firm with Thu airy inapsdon division.
GRFASE/INDUSTRLWASTEINTERCBPTOR
GRADING PEE
CERTIFICATE 017 EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
Cnisacctim need not be completed ifthe permit is faros hrodmddillara(5100)
SEWER - SANITARY - STORM EA. 2001,11'.
INERGY ME
or tax,.)
I certify that in the perfo..ox, I lot weak for which this permit is issued, Ishall WATER HEATER W/VEMP/ELECTR
not employ any person in any n order so as m become subject to toe Workers
PAID
Compensationlawsof Califcmia. Date
WATER SYSTEMfFREATING
Date Receipta
Applicant
NOTICE TO APPLICANT: If, after making this Cenifhcate of Exemryion,you should
NEW RESIDENTIAL PLMIL SQ, Ff.
Ty, 'AL
become subject o the Workers Compensation provisions of the Labor Code, you must
BUILDING PER
fonbwitIt comply wit such provisions or this pcmdt shill be deemed revoked
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 moehy affirm that them is a commission lending agency for the performance of
ELECTRIC FEE
the work for which this permit is issued(Sm. 3097, Civ. C.) TOTAL:
Lender's Name
Leaders Address
QTY.
MECHANICAL PI7RMIT
FEE
PLUMBING FEE
I certify that I have and Gis application and time that the above information is
MECI IANICAL FEB
correct. Iagrce to comply with all city and county ordinan¢sentl stem laws rclmingm PERMIT ISSUANC12
building construction, and hereby nmhmim represcrmi vas of This city nit enter upon the
CONS'1'RUCTIONTAX
above-mentioned property far inspection purposes. ALIIIR OR ADD 3'0 MECI I.
(We) .9. m save, indemnify and keep harmless the City of Cupertino egaina
Iiubilitics,judgmenls,costs and expenses which mo many wity.mmic against said City
AIR IIANDLING UNIT(TO lOJOUCFM)
ce f the gaoling ort ;
/penny,//
AIR HANDLING UNIT (OVER 10.000 CFM)
_
Slgmnu pplicm amrucmr Date EXHAUST HOOD (W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNITOO 100.000 BTU)
Data Re cipt It
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertim Municipal Cade, Chager 9.12, end the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL
Cotic, Seaton 25532(u)7
❑
C1 Yes No
VENTILATION PAN (SINGLE RESID)
ISSUANCEID 'FE
I1 A tl w
IfO11.HR-COMP (.111P OR 100,000 BTU)
Will theapPlicturomfature mild rUcavepann useequipmemordevices whichemit
hazardous air contaminants as defined by the Bay Area Air Quality Management
-
BOILER -COMP (OVER IW,IX10 BTU)
District?
'
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
Aura 2 41994
1 have read the haza dmfs materials u quiremcros under Chapter 6.95 of The
VL�ii
Califurnin Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
Cn I IPIV
it my respom ity m the
eget-moments ame
CITY vi wr
roloodlof'
OOccupant of the requirements which matt be at prior m issuance aro certificate of
whichheat Priorof Certificate
or
ISSUED BY:
wner o
Owner or authonud agent Dae TOTAL:
OFFICE