26630APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
.A
" DING EL. TRI AL
-
PERMIT NO.
�i Cv C
APPLICATION/PERMITPLUMBING
MECHANICAL.
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BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
G v
BUILDING ADDRESS:PHONE
SANITARY NO.
APPLICATION SUBMITTAL DATE
'OM��
"�` `yy�`llA� VFW
UNIT# LOTH
�a�
OWNERSP.:
LIC
CONTRACTOR'S NAME:
NO:
NIC
El
CONTROL #
I e_ G �P G I'/C'
4q
bre-T/FNGINF,GR: a S. � qq ADDRESS:o 3 q
;,
CONNTA PHONE:
QTY. ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
yycooa 3-77-7Y1?,
PERMIT ISSUANCE
❑
❑ ❑
�_Aalies
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
[hereby affirm prd (commencing with
of 3 ofthnsedunss
Section eons) of pivision 3 of the Rosiness and Profeasi0ns Code, end my license is in
PmfnsofChapdr and
PANELS
full force and effect
✓Vl `V
Licens ss Inoontr
UP TO 2M AMPS
Contractor
201 - 1000 AMPS
ARCHITECTS D DECLARATIONOVER
1000 AMPS
'SQ. FT. FLOOR AREA
1/SQ. FT.
1 understand my plans shall be used as public mcords.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER. TION
SPECIAL CIRCUIT/MISC.
I hereby affirm the[ I ata exempt from the Cosi n
om
the CommitteesLicense Lew for the
following reason. (Section s; Co
Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
which requires permit consumer, improve, demolish, or repair any swmure
issuance, re quires t e pplic
prior to slicenedprsunttoth theapplicantof Permit 'sLicefile a se statement
POWER DEVICES
that he is licensed pursuant m the provisions of the Contractor's License Lew (Chapter
the Co La
9(commencing Division SoflleedexBusiness and Professions Code)
$refrom
SWIMMING POOL ELECTRIC
VALUATION
xemwith
and m
onbal67i31.5 by anyopfmmnnd the basPermit subject. thcdexemptw Any vimmaltnof
Section by anyapplicantforupermit subjects tM1e applicant wit civil penalty of
OUTLETS - SWITCHES - FIXTURES
3100-0 0
nor morethan
than hundred dollars
❑ Las refve
yemp. compensation,
NEW RESIDENTIALELECIR _SQ. FT.
/
STOR1IfE�S TYPE CONSTRUCTION
work,afthepmperty,ormyemployerlorofwogesasalei(sole
will Professions La emd forsale
Ccdeh Tie durefsnot is License apply to an, Business
and Professions Code: The Comractors Licrnee Lnw does not apply ro an owner 0f
L f D A II 1
�"�` L r Itll \Vp
progeny who buildsor improves thereon, andwhsdoessuch work himselforthrough his
n employees, providedthmsuchimpmvementsareaotlntend orofferedforsale. If.
(
O C. r ft�RES. UNITS
however, the building or improvement is sold within oneyearof completion, the owner-
TOTAL:
IgF�Ci
builder will have he burden of proving that he did not build or improve for purpose of
sale.).
❑ haz0wnerofthe progeny,amexdusively contracting with licensed contractors t0
QTY. PLUMBING PERMIT
FEEDA
140
FL o o N
construct the project (See ]044, Business and Professions Code:) The Contrector's
-
LicenseLowdosonotapplymanownerofprogenywhobuilds mimprovesthereon,and
PERMIT ISSUANCE
who contracts for such projects with aconarman(s) licensed pursuant to the Connectors
License Law.
ALTER FA
( )
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this mason
BACK FLOW PROTECT. DEVICE
OUI SIDE FEES
SANITARY YN
RECEIPT#
Owner Date
WORKMAN COMPENSATION DECLARATION
pRA1N$-FLOORROOFAREA, CON.
, , .
SCHOOL TAX Y N
I❑ Ihereby affirm that i have a certificate ofconsent to self -insure, or a certificate of
FIXTURES -PER TRAP
RECEIPT#
PARK FEE Y N
Wurkers'Csmpensalion Insurance or ecertified copy thereof (Sm. 39M, Lab CJ which
covers all employee's under this permit.
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Policy #
Company
❑ Certified copy is hereby furbished,
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is Eledwith rhe city inspection division
GREASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be Completed ifthe permit is forone hundred dollars($100) SEWER - SANITARY - STORM EA. 200FL
or less.)
I certify that in the performance of the work for which this permit is issued, l shall WATER HEATER W/VENT/ELECTR
es
not employ any person in nay m as to become subject to the Workers'
PAID
Compensation Laws of Celifomia. Date
WATER SYSTEMITREADNG
Dem Receiptq
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE �>
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
ELECTRIC FEE
thTOTAL:
e work for which this pemut is issued (Sea 309], Co. CJ
Lenders Name
Lenders Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify that I have read this application and state that the above information is
comm. I agree to comply with all city and county ordinances and stale laws relating is
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby amhorim representatives of Nis city to enter upon the
CONSTRUCHON TAX
almve-menthered property for inspection purposes. ALTER OR ADD TO MECH.
(We) agree to save, indemnify and keep hmmless the City of Cupertino against
liabilities,judgments, costs andexpenses whichmay in anyway accrue against said City
AIR HANDLING UNIT(TO 10,00) CFM)
in oonsequrrim.f rho granting of @is K
(/
AIR HANDLING UNIT (OVER 10,00) CFM)
nmureof Applican4Contmmr Dam EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 101,000 BTU)
Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
HEATING UNIT (OVER 100,00(i BTU)
L:
Code, Section 25532(e)P
13 Yes 11 No
VENTILATION PAN (SINGLE RESID)
ISSUA C TE
Will the epplicnmorfuwrebuildingwcopanmi
tuseegsipmentordevicca whichet
BOILER -COMP (3HP OR 100,(Kq BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management
(OVER IOO,BTU)
100,004)JUf�
District?
2`'�
1113BOILER-COMP
Yes No
NEW RESIDENTIAL MECH.-SQ. FT.
����
/x
C11
1 have read the hazmdous materials requirements under Chapter 6.95 of the
Cnlifomia Hcalth & Safety Code, Sections 25505,
Y U• In I/I-CT7
25533 and 255M. I t ndersmnd that
I OvU
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be in prior to issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or aulhorized agent Data TOTAL:
OFFICE