26345 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING TIDENTMECHANICAL
FIC
BUILDING PROJECT IDENTIFICATION 26345
BUILDING ADDRESS: �j SANITARY NO. APPLICATIONSUBMITTALDATE
/� C
UNIT LOTp
0WNERSNAME- PHONE: CONTRACFOR'S NAME: LIC NO: N/C CONTROL#
S // Q
ARCHITECT/ENGINEER: LIC NO: RES
&> - Sevya I! HlPr�J�S sE 2?
corvTAcr: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nwz I hereby affirmthat l am licensedunderprovisionsofChapter9(commencingwim
PJ00 Section]000)of Division 3of the Business and Professions Code,and my license is in PANELS
CU full force and effect.
F$W License Class - Lic.k UPTO200AMPS
an Dale Contractor. 201-IOOOAMpS
ZOrxir'� ARCHITECT'S DECLARATION OVER 1000AMP5 $/SQ'FT'
CZ-0
I understand my plans shall be used as public records.
Fp W SIGNS ELECTRICAL ` ^ II '�1� II� F1
QQ'' F�
Licensed Woftvnional 1� 111'/jltl
raj 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /,
XOU I hereby affirm that I am exempt fiom the Contractor's License Law for the &7q
'7//
W 30 y following reason.(Section]031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE MST. O
1'13 y a which requires a permit to construct,aha,improve,demolish,or repair any structure CPOWER DEVICES W>� prinrtoite issuance,Wsa requires the
not for such Permit m file a signed statement -
ty❑t
0C'
that he is licensed pursuant to the provisions of Ne Contrxmra Liceme Law(Chapter
rt.go 9(commencing with Section)Bhh)af Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Wor fiat he is exempttherefrom and the basis for the alleged exemption.Any violation of OIITLEfS-SWITCNPS-FIXTURES
�G Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of
C1 not more than five hundred dollars($500). S NEW RESIDENTIAL ELECTR .
m 11I,asownerofthepropeny,ormyemployeeswith wages as@eirsolecompeasafian, Q FT. STORIES TYPECONSTRUCTION
will dothe work,and the structureis not intendeloroffered forsale(Sec.4044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
propenywhobuildsor improves thereon,andwhodeas such worifienselforfiroughhis OCC.GROUP RES.UNITS
ownemployees,provideithat suchimpmvensents=mtintendedorefferedforsale.If,
however,the building orimprovement is sold within oneyearof completion,the owner- TOTAL:
builder will have the burden of proving chat he did not build or improve for purpose of
sale.).
❑ I,asowneroftheproperty,mnexclusivelycontmctingwitliccnsedconvacionto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the Indirect(Sec.7044,Business and Professions Cod)The Contractor's
License Law does not apply to an owner ofproperty who builds orimproast menton,and PERMIT ISSUANCE
who contracts forsuch projects wit econtractor(s)licensed punuaato the Contractor's ALTER FA FEE SUMMARY
License Law. (- 1
❑ I am mxtmpt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y N
Owner Date RECEIPT as
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND. SCHOOLTAX YN
❑ Thereby affirm thmlhaveacertificaa of cnnxntmself-insure,oreceruficarc of RECEIPTtl
FIXTURES-PER TRAP
Workers'Copicycotionlnrfluncerount. ified copy tarsof(Sec.3g00,LabCJ which PARK FEE Y N
rs all employee's under tis permit GAS-EA.SYSTEM-I INCA OUTLETS REC I
Policy p BUILDING DIVISION SION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cinified copy is hereby foralmod.
12 Certified copy is filed with to city inspection division. GREASFpNDU$TRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ME
COMPENSATION INSURANCE
(This section madma becompleuM itis,permit is Interim hundroddo11rs($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject an the Workers PAID
Compensation Lawsof California. Date WATER SYSTEM/IREATING Date Receipt
Applicant I
O NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
V) become subject to the Workers Compensation provisions of to Labor Code,you must
a ; forthwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a comm ction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work far which this Permit is issued(Sec.309],Civ.C.)
Lender's Name -
Q U Lenders Address - QTY, MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and state that the above Intercalation is
correct. I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
MECHANICAL FEE �s
to building construction,and hereby aumonsumpresemativesofmiscity to enter uponthe
V Z move-mentioned Property H.
for inspection purposes. ALTER OR ADD TO MECCONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judg cuts,weer and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I000ll CFM)
in emis,tion file gr nt of this pemrii.
l v AIR HANDLING UNIT(OVER 10,000 CFM)
S' awns of Iicant/Csomet r 5 S--
Date EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt if
Wills applicant or Towne building occupant amre or handle hemrdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and Ne Rush and Safety HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25532(a)] VENTILATION PAN(SINGLE RESID)
ElYes 11 No
Willmee licantnrfutrebuildio BOILER-COME(3HP OR 100j"BTU) ISSUANCE DAT
pp goccupamuse equipmemordeviceswhichemir
hazardous air contmminwts as defined by the Bay Arent Air Quality Management BOILER-COMP(OVER 100,W)BTU) WAY p 5 1994
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
CFS 1 w,
1 have read the hazardous materials requir encs odder Chapter understood
of the
if the uil Health s Safety Cade,Sections 25505,t itis sad responsibility
1 understand that
ifcubuildinge re not currently have atenant.thatitis myrespnnsibila ernotify me
occupant of the requirements which most be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date ISSUED BY: