26656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B L I G-ELECTRI A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26656
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(tog Z gE Q ��re Lt' G,,,pe.�F�►w eA OT# //� Q
UNITM LOTH Q0
OWNERS NAME' PHONE: CONTRACTOR'S NAME: LIC NO: ❑
rt4 Kao
ZZ N/C CONTROLN
•ARCHITECI'/F.NGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
v Z L 8062- QTY, ELECTRIC PERMIT FEF.
BLDG ELECT PLUMB MECH
5 �, j PERMIT ISSUANCE "I El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L�
nwz Ihereby affirm that l am licensed underprovisions of Chapmr9(commencing with JOB DESCRIPTION
�i100 Seefull ioae and iffid effect.
Division Sof the Business and Professions Cale,and mylicemeis in PANELS �s ��� 6U,
ysU
fullforceClydeffwt �r�4..�/
<Z Li se Class LieN UP T021XIAMPS
y y Date Con[mcter 201-IOW AMPS
ZOy� ARCI BTECTS DECLARATION OVER 1000 AMPS SQ.FLFLOORAREA $/SQ,Fr.
O z- 1 understand my plias shall be used as public ovemrds.
SIGNS ELECTRICAL.
Q� i0j Lmensed Professtonel
C �< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
X 3 U 1 hereby affirm that I amexempt from the Ci ntrnetols License Law for the
cull O following reason(Section 7031.5,Business and Professions Code:Any cityor county TEMP.METER OR POLE INST.
m which requires a Permit to construct,alter,improve,demolish,or repair any stmetme
a� prior m its iswance,also requires theapplicamt fimsech Permit to file.signed statement POWER DEVICES
W p� that he is licensed pursuant the provisions ofthe Comeactods License Law(Chapter
C tv, 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,ern or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any apPlieant for a Permit subjects the applicant to a civil penally of OUTLETS-SWITCHES-FIXTURES
y^s M of rcthan Bva ha idreddoner.(s5W).
as owner ofthe property,many employees with wages as their sole compensation, NEWRESIDENTIALELECIR _SQ.FT. E�OOD
TYPNCONSTRUCTION
LB-- willdot ork,andttllm ucmreisnotintendedofofferedforsale(Sec.7N ,Business
and Professions Cede:The Contractor's License Law does not apply to an owner of
property who bui Ids or improves thereon,and who does such work himsel f or through h is
nemployees,prnvidedthatsuchimprovements are notintendedoroffercd forsele.If, -RES.UNITS
however,the building or improvement is sold withiaoneyearofcompletion the owner.
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,asownerofthepmpenyamexclusively contracting with licensed contmcomro QTY. PLUMBING PERMIT FEE APN
construct the project(Sec.9044,Business and Professions Code)The Cm ancho's
License Luwdoes not apply wan mwmerofproperty who builds orimproves thereon,and PERMIT ISSUANCE
whoeotnmctsforsuehprojectswithac ntrator(s)licensed pursuant tothe Contractor's
License Luw, ALTER-DRAIN&VENT.WATER(EA) FEE SUMMARY
❑ I em exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT%
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX YN
❑ I hereby affirm that l have a certificate ofconsenrto self-insure,oracenlficate of FIXTURES-PER TRAP RECEIPTS
Workers Compensation Insurance or a certified copy thereof(Sec.3gW,Lab C.)which 4ENMGY
E Y N
covers all employee's under this permit GAS-EA.SYSTEM-)INC.4 OUTLETS RECEI"#—
BUILDING
Policy M DIVISION FEES
Company GAS-EA.SYSTE 'OVER4(EA) EC FEE
❑ Certified copy is hereby famished.
Cl Certiped copy is filed with the city Inspection division. GREASEiINDUS ER,EPT6R G PECERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP . ECOMPENSATION INSURANCE
is fntatchuadruddullars($IW) SEWER-SANIT RY-S RMEA.200IT. FEmr lees.) qL�pper�,I certify that in the Immmance ofthe workfn-which this Permit is issued,I cha11 WATER HEA W/VENTgq.y(Cnm employ any person in any manner so"to become subject to the Workers'
z Compensationl.awsof Califands, Dae WATER SYSTEM/1'REATING Date ReceiptN
QApplicant NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,youshorld NEW RESIDENTIAL PLMB. SQ.FT. TOTA
,� to become subject 10 the Workees Compensation provisions ofthe Labor Code,youmus[
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
y (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.30197,Civ.C,) T ELECTRIC FEE
Lenders Name
O U Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
GkI I certify that I have read this application and state that the above information is
carrier lagreemcomply with all city and county ordinances end smte laws relating to PERMIT ISSUANCE MECHANICAL FEE
�^ Lo) building construction,and hereby authorize representatives of this city to enter upon the
V z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabllities,judgments,costs andexpenses which may in any way accrue against said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
segue o he granting this permit.
�D AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicant/Contmotor D Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DI LO$URE HEATING UNIT(TO 100,000 BTU) Date Receipt%
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cede,Chapter 9.12,and Ilia Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTA
Cade,Section Y5 32(e)P
❑ ❑No VENTILATION FAN(SINGLE RESID)
Will the air commutation,
s building occupantuse equipment Quality
BOILER-COMP(311P OR IW,WO BTU) ISSUANCE DATE
hatr•
District'
air cmnmminants as defined by the Bay Areu Air Quality Management BOILER-COMP(OVER IW,W BTU) �y
District+
❑Yes 11No NEW RESIDENTIAL MECH. $Q.Ff. A
I have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that - (/Itl
if the building does note men ly have a tenant,that it is my responsibility to notify the C/'r 199
occupant of the requacrin as which must be met prior to a ficm
Issuance of Cerie of
Occupancy.
Owner or smth mined agent pate TOTAL: ISSUED BY:
OFFICE