26865 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ELECT PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26865
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ee ^a3L I A/ ,,yy SANITARY NO. APPLICATIONSUBMITTALDATE
10208 {,ATJS PL -e dI/P[..KTeYMIT# LOT# yyg Wl
OWN SNAME: PH NE: CONTR OR'SN ME LIC NO: v �`
�� L.w! AjA)c—LI C��.-a'7� NIC CONTROL#
ARCHITECT/ENGINEER: L- •LTC NO: i ADDRESS: ❑
I
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
- BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
09z Ihereby affirm thud amlicensed underprovisions of Chapter9(commencing with
FJ C)0 Section]000)of Division 3 of the Business and Professions Cod,and my license is in PANELS
q full force and effect.
Ezz� License Class Lia# UPTO200AMPS
y=y Dale Contmcmr 201-IO00AMPS S PI'.FLOOR AREA E/SQ.FT.
jj zoy� ARCHITECT'S DECLARATION OVER 1000 AMPS Q
C z-Q 1 understand my plans shall be used as public records,.
ry t t�i SIGNS ELECTRICAL
j g ,,,) Licensed Professional
Z OWNER-BUILDER DECLARATION SPECIAL CD2CUIT/MISC.
00.0 Ihereby affirm Nm 1 nm exempt from the Contrecmi a License Law for its,
tsl'3 C...-i fallowing reason.(Section]031.5,Business and Professions Code:Any city or emary TEMP.METER OR POLE INST.
F❑f�rte which requires a permit to construct..)to,improve,demolish,or repair any structure
oe�7 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
Gp that he is licensed pursuant olthe provisions of the Comrentme.License Taw(Chapter �„
0.0 9(commencing with Section]WO)of Division 3 of the Businessland Professions Code) SWIMMING POOL ELECTRIC VALUATION
iW N or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-
PIXNRES
G Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR C 5 .FT.m ❑ I,esmwneroftheprmpertYmrmyemployeeswithwegesas[heirsolecompenee[ion, Q STORIES TYPE CONSTRUCTION
y will dothe work,and thestmctureisnotintended m offered for We(Sec.]044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
propertywho bui Id s or improves thereon,and who does such work himself or through hi s
ownemployms,pmvidedthatsuchimMvementsmnotintmdMoraffemdfmsMe.If, OCCGROUP RES.UNITS
however,the building orimprovement is sold within one year ofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owneroftheproperty,amccurtmively contracting wit licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
mmsvua the project(See,7044,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law does not apply m an owner of property who bui Ids or improves thereon,and
who contracts for such projec rs wit a contractors)licensed pursuant m the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ Tam exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y N
Owner Date RECEIPT'#
��00S- IryJOQ�di F, A, O
WORKMAN COMPENSATION DECLARATION 1I � � SCHOOLTAX Y N
❑ Ihereby affirm that l have a certificate ofcomentto self-insure,or a certificate of %TURES-PER TRAP RECEIPT It
Workes'Compensation Involves,or a cemfied copy thereof(Sec,3800,Lab C.)which �i PARK FEE Y N
covers all employee's under this permit -6A.5 M 4 E,' RECEIPT'#
Policy# I BUILDING DIVISION FEES
Company GA .SY -O (EA) PLANCHECK PEE
❑ CeitifiedcmpyisherebyfumishaL _
❑ Certified wpy is filed with the city inspection division. REASE/lNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed not be completed ifthe permit to far one humedda11ms($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
odoaIr
Ic<oy That to the pin an,neofthe work To
become
this ubject to the Workers
WATER HEATER W/VENT/ELECfR
Coemploy any person in any manner so as m become subject to the Worker% PAID
Compensation Laws of Celifomie. Dem WATER SVSTEM/IREATING Date Receipt# ;
Q z Applicant -
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
ti become subject to the Workers Compensation provisions of Ne Later Code,you must
�i > forthwith comply with such provisions or This permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm That there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
r� Lender's Name
Lendeis Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that I have read this application and state that the above information is MECHANICAL FEE
correct.l agree to comply with all city and country ordinlances and state laws relating to PERMIT ISSUANCE
f^ V) building construction,and hereby amhoriae mpresenti Ives ofthis city to enteropon The -
(� y above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCf1ON TAX
F7 (We)agree to save,indemnify and keep harmless The City of Cupertino against
liabiliti In ents,costs andexpenses which may in any wayaccrue alnstsaid Ty AIR HANDLING UNIT GO 10,000 CFM)
o0the gpnJing file permit I 1 IR HANDLING UNIT(OVER IBM CFM)
Siattire of Applicam//C000wttnr Date EXHAUST BODO(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle Inrundous material HEATING UNIT(OVER 100.000 BTU) T
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
r�
Code,Ss,etl 25532(
11Yes ❑No n)1 VENTILATION PAN(SINGLE REBID)
❑
Will theapplicantorfuturebuilding occup.nt use equipmentordeviceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE QATE
hamrdous in commissars as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,"
District? 13 AUG 11 M4
Yee ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the haaardous materials requirements under Chapter 6.95 of the �� LI" 1#Uf CIY 1 IIVLJ
California Heath&Safety Code,Sections 25505,25533 and 25534. I understand that
lithe building does not currently have a tenant,that it is my respmnabiltry to not the
occupant at the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner orauthorized agent Date TOTAL: ISSUED BY: