26428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD NO-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 4 2 8
BUILDING PROJECT IDENTIFICATION
BIJILDING ADDRESS: ///�/�j�/yam SANITARY NO. APPLICATION SUBMITTAL DATE
03 � a�'�/ t UNIT# LOTH
O E p1E;� A)A) P O �� - N ACTO 'SNAME �� N0. NIC CONTROLN
A C D'BCI'M1VLVNrR: ��LICNO;_��� ADDREg E
CONTACT: PHONE:576BUILDING PERMIT INFO 6 � � QTY. ELECTRIC PERMIT FEE
B_ LIy'i B�ECT PLUMB MECH
PERMIT ISSUANCE �Flj !Yr—y � ❑
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-RESIDENTIAL 30 CRIPTION
QWZ I hereby affirm that l am licensed underprovislonsoChapter9(commencing with
[ 00 Section 7")of Division 3 of the Business and Professions Code and my license is in PANELS
y Intl intestinal affect `' I#1 .
E Z 'ease Class Lic.0 �'1 (� UPT0200AMPlS -
mQ me Cmbactor 1-1000 AMPS
y= AR H CTS DECL OVP.R It100AMPS ,�S/SQ'IT.
�.,W I understanJ my plans shall be used as public records. fIV6�� /4v'VII `a'F
SIGNS ELECTRICAL
%C) Lmenud Professional
�J�Jy OWNERBUILDERDF.CLAourtra SPECIAL CIRCUIT/MISC. �O
X O m 6- I hereby affirm that I am exempt from the Contractor's License Law for the �J
W E+t following reason(genion]0am Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
ON�5 which requires a permit m creamer,alter,improve,demolish,or repair any structure
a, Pon' its issuance,also requires the applicant for such permit file a signedrimeament POWER DEVICES
O0 that he is licensed pursuant in the provisions of the Contractor's License Law(Chapter
Lg Q ' 9(commenciag with Section'/00thw[Division 3oflue Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATIONf/�
armed he isexempuherefromand materials forthe allegedexempther Any violntiono OUTLETS-SWITCHPS-
f-Z Q Section 9031.5 by any applicant for a permit subjects the applicant ro a civil penalty FIXTURES ^� .�p
❑z not more than five hundred dollars($500). (�J{/
W m ❑ I,asmwneroftheproNny,orm em to eeswithwe esaemeirsolecom NEW RESIDENTIALELECTR _SQ.FT.
Y p Y B lxnesinen. STORIES TYPE CONSTRUCTION
m 3—, will dothe wons and the she Comm ncemended nte Law ed does not
apply to an Business
and Professions Cade:The Contractors License Law does or apply to am owner of
properly whnboilde arimproves thereon,and whodoes such work Nmselforthrough his
employees,progini improvement
met earofcuroffered thf owner. OCCGROUP RES.UNITS
however,theavet a burden
of proem issoldwithinoneyearorimroefortheowner-
builderwillhavetheh�rdenofprmvingthathedidnot build or improve for putpou of
sC TY, PLUMBING PERMIT FEE FLOOD ZONE
❑ I,as mwnerofthe prnpeny,am exclusively contracting with licensed contractors to Q APE
maxima[the project(Sec.7144,Business and Profession GMC:)The Cnmracmr's
License Law docanotapply manownermfproperty wholamidsorimprovesthemon,and PERMIT ISSUANCE
who commas forsuch projects with acontractor(s)licensed pursaanuothe Contimmo s
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I stn exempt under Sea. B&P C For this meson BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dale DRAINS-FLOOR,ROOF,AREA,CONI. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
JF' ❑ (hereby affirm mat l have a certificate ofmaxam to self-insure,or a certificate of FI%TURES-PER TRAP RECEIPT#
Worke-'C Compensation Insurance or acerified copy thereof(Sm,3800,Lab C.)which PARK FEE Y N
covers ell employee's under this permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISIO
Company GAS-EA.SYSTEM-OVER4(EA) PLAN FEE ..r#
11Cetiified fa
copy is hereby notified.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WAS RCEPfOR GRADING FEE
CERTIFTCATE OF OMPENSATION INSURANCE
WORKERS' GREASE TRAP
COMPENSATION INSURANCE R OIL I
or les
section need not he completed Rita permit is for one handraddollars($10() SEWER-SANITA -STO .2 \. TNM
V
45
1 certify that in the performancepermit is of me work for which this peris issued,Ishall WATER HEA W/VENT/P. it
not employ any person in any m er so as to become subject m the Workers'
Z Compensation Lawsof Califomia. Dare WATER STEM/TR NO Date Receipt#
0 O Applicant
NOTICE TO APPLICANT:IL after making this Canificare of Exemption,you should NEW ESIDENTIALP SQ.FT. TOTAL:
rry become subject o the Worker's Compensation provisions ofthe Labor Code,you must
jforthwith comply with such provisions or this perm,shell be deemed revoked. BUILDING FEE 'y
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE —�
Lender's Name
O U Lender's Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LkI 1 certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingeonstrution,and herebyauthmize representatives ofthis city to enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Caperton against
lia 'lities,jadgments costs end expenses wf►_ — any way accmeegainst said City AIR HANDLING UNIT(TO IO,OW CFM7
consequence gr of thio permit.
eyy�'tq�/WC AIR HANDLING UNIT(OVER 10,000 CFM)
9gne are of Applicant/Cnntredgr DamEXHAUST HOOD(W/DUCE
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building oowpam store or handle financiers material
as defined by the Capetian Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER Hfir"BTU) TOTAL:
Code,Section 25532(ep
13 Yes 0N VENTILATION PAN(SINGLE RESID)
BOILER-COMP ISSUANCE ATE
Willtheappllcant orfumarmilding occupamues egaipmentordevices which emit (3HPOR 100,000BTU)
District?mountainair contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Rf A
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. r �'9
I have Health
the haroSafety
Code,
materials 5505.25533 under Chapter understand
of the - MAY 31 �g
California a read t Safety Code,Sections 25505,requirements
and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the t
occupant of the requirements which must he met prior to issuance ref a Certificate of
Occupancy. ClI lL
I Ih� �y
�,�jrIIIVU
Owner or authorized agwt Dete TOTAL: ISSUED BY:
OFFICE