26230 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26230
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/UNIT* LOTH
OWN R PHO* I�/ CO R'S M LIC NO:� NIC CONTROL*
ill .ARCHITECT/ENGINEER: LIC NO: / ADD B Si ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED thatIaCnsed un CTOR'SDECLARATION APPLIANCES-RESIDENTIAL / PTI
OCZ (hereby affirm N licensed uACTORvlsDECL RAT( 9(cmmmencingwilh
WOO Section TXq)of Divixinn 3 of the Business and Professions Code and my license is in
PANELS
to ut full ns Ciroe and efkc ' - * r UP T0200 AMPS
66 ZZud Lior Clax li b C Lic.
vFidy pvte OVA
201-1000 AMPS
z to�' RCHITECTSDECLARATION OVER If100 AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
O Z—❑ 1 understand my plans shall be used as public records. Il I�
C^�¢ SIGNS ELECTRICAL I LL fl 1!�
C < Licensed Professional l_ E
OWNER-BUILDER DECLARATION SPECIAL GIRGGIT/MI p p f
OaF 1 hereby affirm that 1 stn exempt from the Conuacmr's License Lew for the - 1`I`ll'I Il'e
u�3�m following reason,(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER O LE INST. LV
which requires a cemlit to construct,alter,improve,demolish,or repair any svucmre
�_Yn phormilsissuance,also requires the applaud forsuch pernilto Bleaxquad statement POWER DE ES
tyG A 0 that he is licensed putau om 1.the provisions of the Convacmrx License Law(Chapter
9(commencing with Section]000)of Divixinn 3 of the Basin,.and Pmfexsionx Care) SWINJOGGPOOL ELECTRIC LVALUATION
or that he is exempnhcrefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
0 not more than five hundred dollars($50)). NEW RESIDENTIAL ELECTR 5 .
wuI 1:11,asownerofthepmo rty,ormyemployeeswithwagesastheirsolecompensation, Q FT. STORIES TYPE CONSTRUCTION
y3� will do the work,andthe swcture is not intindedoroffered forsale(See 7044,Business
and Professions Code:The Columbines License law does not apply to an owner of
progeny who bu ilds or i mproves themon,and who does such work hi mself or through his
own employees,pbrlded thmsuchimprovemenmumnotinwndcdorofferedforsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within oneyear ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ale.). TY, PLUMBING PERMIT FEE FLOOD ZONE APN
ElQ
Las ownerofthepropeny.unexclusively convecting wiN licensed convectors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not applyto an ownerofpropeny whobuilds orimproves thereon,and PERMIT ISSUANCE
who contracts for such pri with econtracmr(s)licensed pursuaauo the Committees
License Law. ALTER-DRAIN&VENT-WATER EA PEE SUMMARY
- ( )
❑ 1 sm exempt under Site B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner pate RECEIPT N
WORKMAN COMPENSATION DECLARATION
DRAINS-FLOOR,ROOF,AREA, SCHOOL TAX YN
CI FIXTURES eHlrm metlhnve eoertifleam of consem mxelf-insom,oracenlfleete of FIXTURES PER TRAP RECEIPT
Workers'Compensation Insurance or a certified copy thereof(Sce.3800,Lab C.)which - PARK FEE Y N
covers all empl I a it. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT*
Policy* BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Crud copy is h reby furnished.
ani bed copy is filed with the city inspection division. GREA6Eg1JDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
indirection need not b,completed ifthe permit is forone hundreddollars( UXE SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orless.)
I rectify that in the performance afthe work for which this permit ie issued,Ishan TTATER HEATER WNENWELECTR
not employ any person to any manner son t'�mtauWNb t6�9e Workers' PAID
O .z APpmpe�s'tion Laws of California. Dote 1.1 J _ 9 77 WATER SYSTEM/1'REATING Data Receipt*
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
U) become subject to the Worker's Compensation provisions of the Labor Code,you must
Lei , forthwith comply with such provisions or this permit shall he deemed revoked, BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Iherebyaffirm hot the. construction lending agency for the safamuchoe of
O Ne work for which this permit is issued(Sec.3097,Civ.C.) I TOTAL: N ELECTRIC FEE
IY H.y Lender's Name PLUMBING FEE
O Lender's Address QTY, MECHANICAL PERMIT FEE
V 1 certify that 1 have read this application and state that Ne above information is
correct. l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MECHANICAL FEE
�-' building emcouction,andhereby amhorizerepresemvrivesof thiscity roarer upon the CONSTRUCTION TAX
V 7 above-memioned property for inspectionR
puoses. ALTER OR ADD TO MECH.
A (We)agree to save,indemnify had keep harmless the City of Cupertino against
Iiabililws,judgmemi.,ceasind expenses which mvy many way necrue egainstssid City AIR HANDLING UNIT(TO 10."CPM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicam/Comrucmr Date EXHAUST HOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU Date Receipt*
Will the applicanter fmure bu mg occupant store or hand Is hazardous material HEATING UNIT(OVER1 00 BTU TIAL:
as defined by the Copeman Mu pal Cade,Chapter 9.12,end the Health and Safety )
Code,Section 25532(e)P
11 Yes NVENTILATION PA INGLE RESID)
a
ISSUANCE DATE
Wilhhevpplicanmrfmure buildJ' ocoupanl useegvipmmtnrdevicw whichemit BOILER-CA (3HP OR 100,000 BTU)
hazardous air conlaminamZ;ed by the Bay Area Air Quality Management
• Distinct? BOILER/
OMP(OVER 100,000 BTU) kxss p
A
❑Yes ❑No N SIDENTIAL MECH. SQ.FT, r All)
1 have read the hazardous materials requirements under Chapter 6.95 of the APR .9,6
California Health&Safety Cade,Sections 25505,25533 and 25534. I understand that ��
ifthebuildJJJyyy ave a novngthat it is my responsibility 0 notifythe
Occup nt mingdaf tl�jf nprt not rently hch!post et prior to issuance of a Cenificam of Cp
or
Owne"l maintmedagem pale TOTAL: ISSUED BY:
OFFICE