26712 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILDING-ELECTRICAL. PERMIT NO.
6 APPLICATION/PERMIT PLUMBING-MECHANICAL- nC�r� /�
BUILDING DIVISION - 'BUILDING PROJECT IDENTIFICATION- "• Go 1G
BUILDING ADDRESS: SANITARY NO. AFEI.ICA'TIONSUBMITTALDATL
UNIT'# LOT IT
NERSAME: PHONE: C FACTOR'S NAME: LIC NO: w
= - ` N/C CONTROL#
•ASCIII'1'ECUENGINEER: LIC NO: ADOFUESS: u ❑
CONTACT. PHONE: a r t''` f 'y,. • r `BUILDING PERMIT 1NP0
QTY- q ELECTRIC PERMIT+ FEE,
BLDG ELECTPLUMB MECH
PERMITISSUANCE El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OC'L Thereby affirm thin amllcensed underprovisionsm Chapmr9(commentiugwith
FF100 Section 7000)of Division 3 of the Business and Professions Code.and my license is In PANELS
F-W fall forty and _S t -� Pr G
c UA Lice0�C1'1a� � Lic.#,�5 S� ,` UP TO AMPS
y6y Dmq Qmlrucmr��N 201-1000 AMPS
F-y ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA $/SQ.F9'.
ZOy OVER lOW AMPS
O Z'�G Iundenwnd my plans shall be used as public records.
�y u] SIGNS ELECTRICAL 1�
Licensed Professional L tl
CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. / 9
0,U I hereby affirm that I am exempt from the Comf..or's License Law Ter the / u\V I nL12-11TY
W 3 LL h following pea e..(See ion 7031.5,Business and Professions Code:Any cit ,,.ant TEMP.METER OR POLE INST. L cif�C) which requires a permit to construct,almr,improve,demolish,or repair any tructuret2a7 poor to its issuance,also requires the deplicant for such Permit to rile a signed statement POWER DEVICES C, p that he Is licensed pursuant to the provisions of the Contractor's License Law(Chaptu G
P.X, 9(commencing with Section Wild)of Division 3 of the Business and Professions Coda) SWIMMING POOL ELECTRIC
WM, or that he is exempt hemrrom and the basis for the alleged exemption.Any violation of
Q Section 703 L5 by any applicant for apo.it subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
Q et me than rofthnd.ddollors($5(10). NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCTION
yPRE n❑ I,the wrk,adthespertyre is n emperadedwi0wed forele(Serle compensation,
g— will dothewofk,Cde:The Cureistiors License Li fared f,a.,tiply 1.an Business
and Professions Code:The ea tmrema, nd who Law does no[apply m an owner iof
s
property whobuilds or improves th ippo and who does such wad Nmselfonhrough his
own employees,provided that suchimprnvemen[s amnm[in[endW oraffered Poreale.if, OCC.GROUP RBS.UNITS
however,the building or Improvement is sold within one yearefcompletion,the owner- TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose of
sale.)
❑ I,es owner ofthe property.am exclusively contracting wiNliwmed contrnom stn QTY; ` <.PLUMBING PERMIT ` tv FEE,at FLOOD ZONE APN
conswat the project(Seo.9044,Business and Professions Cadep The Con[rector's
PERMIT ISSUANCE
l.i cense haw does not appl y to nn owner of properly who bui Ids or improv es thereon,and
who contracts forsueh projects with acamuctia(a)licensed pursuant o the Contractmea ALTER License Law. PEE SUMMARY'
❑
Tam exempt under Sec. ,B Sk PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT#
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATIONI'AX Y—N-
1 hereb
Thereby afnrm lM1m[haveecenificetem mof con DECLARATION SCHOOL consent mnelf-insu.,ore wrtifioe[a of FIXTURES-PER TRAP RECEIPT'#
recaps ll71mpensatlon lnmrenw ora ceAfied to
thereof(Sec 3800,Leb CJ which PARK FEE Y N
Policy#Ir/ oyea:�nJ¢bs mit. 15 .✓ RECEIPT If
pp SS ll�i f� GAS INC.40UTLETS BUILDING DIVISION FEES
C �'YT // GAS-EA.SYSTEM-OVER4(EAA) PLANCHECK PEE
Corti Tied copy is hereby fil'in heE
❑ Certified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thiswtim need not be o0mpleted ifthe permit is fimmm hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PER
or less.)
I cerif dee in the perforecanceof the work for which this permit is issued.lshall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of California. Date WATER SYSTEM(fREATING Date Rat#
Q z Applicant
C) NOTICE TO APPLICANT:If.after making this Certificme of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. 'TOTAL:
v) become subject to the Worker's Compensation provisions of[lie Labor Cade,you must
forthwith comply with such provisions or this permit shall be deemed revoker. BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ilic.maffirm that the.is awnsprommn lending agency for the performance of
Q the work for which this permit is issued(Sac.3097,Civ.C.) TOTAL: ELECTRIC FEE
LT. ry Lenders Name ` "' ' " ' r 1 °" ' PLUMBING FEE
U Leaders Address QTY.'S° _MECHANICAL PERMITZ zr FEE
C..) 1 dairy that I have lead this ra,bealma and stye thm[he above information >
correct.l agree a comply with all city and county ordinances and state laws relating a PERMIT ISSUANCE / MECHANICAL FEE
VF^ building construction,and hereby nmhoriu repmsemn[ives of thiscity mcnterupan the CONSTRUCTIONTAX
y above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
�i (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,Jud menta,costa and expenseawh¢h me ' any wayaocrue ageintsmdCr, AIRHANDLINGUNIT(TOI0000CPM)
in conseq Rhe gmnti/9g of this permit./J'J�
xa
E. y/_y-, AIR HANDLING UNIT(OVER 10,000 CRM)
Sign are of ApPlicant/Contracme '#y�!!L?F/�- XDate iY— EXI IAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future handing occupant store or handle hazardous material HEATING UNIT(OVER 1(M,t>W B'TU) TOTAL
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(v)R
11 Yes 1:1 Na VENTILATION FAN(SINGLE.REBID)
BOILER-COMP(3I{POR 100,00)BTU) ISSUANCE DATE
Will the apartand pants as deficng by the
Area Air
Management pY p
hawrdous air contaminants as dcfnrd by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
P P1
Disvlm7
Lbuilding
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. JUL - 8 19A A
read the hazardous materials requirements under Chapter 6.95 of the
alth de Safety Code,Sections 25505,25533 and 25534.1 understand that /xF�X.
g does nm currently have a mnant,that it is my responsibility to notify the CII! Urthe requirements which must be met prior to issuance ofa CerdMate ofthorized agent Dam A ISSUED BYM72
OFFICE,