26550001 IPANT Tn FII 1 IN INEnRMATICN WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDIN(T-MEC YMCA
CITY OF CLPESION PING PROJECTID IDENTIFICATION
Bun.nmc nrvlsTory APPLICATION/PERMIT
' BUILDING PROJECT IUF.NTIFICA'1'ION
PLRMI'I'NO.
X 5 5 0
o J J
OUILDING ADDRESS:
�/
8 •YQ �/ U1OOO O A.• UNIT# LOT#
.SANITARY NO.
APPLICATION SUBMITTAL DATE
67 an
OW RS NAME: PHONE:
��
CONTRACTOR'S NAME: LIC NO:
NIC
CONTROL .
PHITLCT/ENGINEER:, LIC NO:
ADDRESS:
i
/-
CONTACT: PHONE:-
QTY. ,ELECTRIC PPRMIT FEE
BUILDING PERMIT INFO
L EIC4 PLALMO MGCII
PERMIT ISSUANCE!S7
El
LICENSED CONTRACTOR'S DECLARATION
mmenense with
ns
11¢000)
APPLIANCES -RESIDENTIAL
)B DESCRIPTION
3 of th Eosised
andProfessions Cod.and
Section7000)Divieien3of[M1e Nosiness and Professions Code. and my license is in
of Division
roll force and eHne9 L ,y� O
me Class' LS .Lir.#
PANELS
UP T0200 AMPS
r.
-
4
Data Gmlmcmr
ARCHITECTS DECLARATION
I undersand my plans shall he used as public records.❑
201-l0k)AMPS
SQ. PT. FLOOR AREA
q -
{01 i.VN
t
$/SQ. F1'.
OVER 1000 AM
SIGNS ELEC9'RICM. 1— I / � I
m 1 1
Lwarced Professional -
OWNER-BUILDER DECLARATION
_ Tr—
SPECIALCIRCIIIDNI CL (I -D.
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 9031.5, Business and Professions Code: Any city or county
— -
TEMP. METER R POLE INST.
which requires o permit to eamstmeh alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such pamtlt to file a signed statement
POWER DEVIC
9 IL—
--
that he is licensed pursuant in the provisions of the Contractor's License Low (Chapter
9(rmphadmingwbhSecdon7000) of Division 3 or he Business and Professions Code)
- - _ -
SWIMMING POOL ELECTRIC
VALUATION
OUTLB'PS- SWITCHES - FIXTURES 1 %
of Nat hers exempt lhelatiom cad the basis!oMealleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjeoa [he appliedu l ton civil penalty of
-
boo
nal mT.aso%nrofthcrOprty,OT($500)'
❑ I, asownaofthepmperty,ormyemployeea with wageses[hdreolaeompensation,
NEW RESIDENTIALELECTR SQ. FF.
ST IES
TYPECONSTRUCION
7f Business
will JotheuonsCde: rdoes
he Cocisnoris LicenseLawnotan
and Professions Code: The, Contractor l.ieense Law tiros not apply to an owner of
property who buildsorimpro calleercon, andwhodoessuchwork himselforthmugh his
own employees, provided that such lmprovementsamnotimendedoroffemdforsale.If,
DEC. GROUP
UNI
T
however, the building orimprov ent is sold within one yearof crmpleden.theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMDING PERMIT FEE
nate.)'
ElI, as ownendthe properly.amexdusively convac[ing with licenseA contradonm
PLOODZONF.
EAP:N:T:S:�
construct the project (Seo. 71044, Business and Professions Cade:) The Contractor's
License Lawdoes not applyto an ownerofproperty whobuilds orimproves thereon,and
PERMIT ISSUANCE
who contracts for such projeoa with aconteactor(s) licensed pursuant to the Conwamrs
Law. -
ALTER- DRAIN & VENT - WATER (EA)
_ FEE SUMMARYLicense
❑ I am exempt under Sea , B @ P C for this reasonOUTSIDE.
BACK FLOW PROTECT. DEVICE
- FEES
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION-
r lhaeb ffrm thntlertifcaifie convent to pelf -insure, ora ecru%cam of
kere'Compenaafirm lnsamorceumnw oracertiRW copy tbereo((Sec.3800, Lab C.)which
covers all employed., under this permit.
Policy #
SCfIOOI. TAX RECEIPT# N
TEXTURES XTURES-PER TRAP �'
PARK FDE Y N
RPAE
GAS - EA. SYSTEM -1 INC.4 OUTLETS
BUILDING DIV 1SIO9IDN FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ CerttHWwpy ishcrebyfumishiSt -
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING IEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE '
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2001"1'.
ENERGY FEE
Cnis section need not he completed ifthe permit is fortune hundred dollars ($100)
or less.)
WATER HEATER WNBNDELECTR
'
Loenify that in the performance ofthe work for which this permit is issued, I shall
not employ any person in say m as to became subject tp the Workers'
so
PAID
Compensationfur sof Califomia. Date
WATER SYSTEM/IREATING
Data Receipt#
Applicant
NOTICE'1'O APPLICANT: If. after making this Certificate of Exemption. you should
NEW RESIDENTIAL PLMB. SQ. Cap
TOTAL: '
become subject to the Worker's Compensation Provisions of the Labor Cade, you must
forthwith comply will, such Provisions or this permit nhall he deemed revoked.
BUILDING PEE !�
SEISMIC ME
CONSTRUCTION LENDING AGENCY
1 hereby affrm that there Is a ronevuaien leading agency for the supordenceor
the work for which this permit is issued (Sec. 3097, Civ. C.)
T /
ELECTRIC FEE
Lender's Name
7
QTY.. MECHANICAL PERMIT FEE,
PLUMBING FEE
r
Lender, Address
I comity that I have read this application and eaathat the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICALFEE
butldingeoasrtuction. and hereby autborizerepreecntatives of this city to enter upon the
above-mentioned property far inspection purposes.
(Wsm agree to save, indemnify and keep th mlless the City of Cupertino against
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
limfoie dgmems, costs and expenses which may into, way income agtinslsald City
AIR HANDLING UNIT CTO 10.01X1 CFM)
'
s qu ace of the granting of rmiL
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCI')
PAID
Signe r of ApplicanUConiwtor - Data
HEATING UNIT (TO 11)0,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER 100,000 BTU7
TOTAL
Will the applicant or future building occupant store or handle hazardous material
as refund by the Criterion Municipal Code, Chapter 9.12, add ilia Health and Safety
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)9
❑ Yes ❑ No
ISSUANCE DATE
Willtheappllcatorfinum building occupant use equipmenmrdevlceswhlchamit
docs an cmorthem s as Aefned by the Bay -Area Air Quality Management
tv
BOILER- COME (311P OR 100,000 BTU)
rte,
/a , #i
6
BOILER -COMP (OVER 100,IX10 BTU)
NEW RESIDENTIAL MECH. SQ. 1'f.
El Yes ❑ No
I have read the hazardous materiels requirements under Chapter erst or the
9 1994
SEP
25533 and 25534. f responsibility to nand that
ifteCalifornia ing Health s of etycur Cade, ently have a hs ant, that the
ifxupirmloftheoplainaur,whinveatetbe Ihaliis rmy rsuanceof ity Confidence
ocupam of the requirements which most be at prior to Issuance of a Cerif7cam of
Occupancy. -
-
ll.y Y VI Ck •I
� ,
ISSUED BY
Owner or authorized agent Dan
TOTAL:
OFFICE