26088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY PERMIT NO.
CITY OF CUPERTINO PLkLMBR+c-mRcnRrl+rcL- 260881
BUILDING DIVISION APPLICATION/PERMIT pUILU1NG PRs9JF:C1'IDRN'TIFICA'fi(IN
SANITARY NO. APPLIGTION SIIBMTITAI.DATL•
BUILDING ADDRESS:
fa, LOT
UN LOTk
O lapyf� CONTRACTOR'S NAME: LIC NO: Nrc CON9ROL41
•ARCHI'IECIENGINEEW LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INP"
QTY. ELECTRIC PERMIT IeCE BLDG - ELECT PLUMB MECH
PERMIT ISSUANCE ❑ *Ap ❑ ❑
LICENSED CONfI!ACTOR'S DECLARATION APPLIANCES-RESIDENTIAL (/�,/��y�. JOU DIFUSCRIPI'10�
Ibeabysffumthat I=licensed underpmvisionsofCheptu9(commencing with `Y '� ' ' yCs
0+100❑ Section?0007.(Division Sof Ne Business and professions Code.andmyliceneisin PANELS
�UZW full force and effect UP TO 200 AMPS
F License Class 201-IOW AMPS
y6y Dam Contractor '� ) TFT�00 /SQ.FT.
any ; ARCHITECTS DECLARATION OVER IOW AMPS
ZO Z- 1 understand my plans shall be used as public records. SIGNS ELECTRICAL
Q �
Licensed Professional //SPECIAL CIRCUITMISC.
OWNER-BUILDER DECLARATION (Q
yyO yU I hereby uffrm that I am exempt from the Contmcmrs License Law fm the TEMP.METER OR POLE INST, p{,
W 3 kfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county
F��ya
.] which requires a permit to construct,alter,improve,demolish,or repair any suacure POWER DEVICES
�!!(}2 pdorto its issuance,alsotaluims the applicant(msuch permit file a signed statement
IKm 00 that he is licensed pursuant to the Provisions oft,Conwcme.License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
6� 9(commencing with Section?")of Division 3 ofthe Business and Pmfessimu Code)
of hat he is exemptshemfrom and the halts for the alleged exemption.Any violation of
G Section 7031.56 applicant for Permit subjects the applicant to a civil Penalty f OUTLETS-SWITCHES-FlXTDRE$
by Pc J PP pe Y°
or inthanfveh propsoAlan(ESWL NEW RESIDENTIAL ELECfR _SQ.FT. STORI' TYPF:CONSTRUCTION
m .thew k..MI dproperry,ormyempendeeswithw.d for.)a(Sea
compensation,
y _ wit othcwonsCde: structure Comsnm imcndese Law
no,,(Sec.?044.Business
and fusions Code:The Cmmecmrs License Law deal ar apply lf an sought of
proputywh.buildsorimprovesthereon,entl who d«sauchworkNmselfor Wooghhic OCCGR UP RFS.UNITS
own employees,provided that such improvements are not intended or offered for sale.If.
however.be building or improvement is sold within one yewcomplmian,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT- FEE FLOOD ZONE APN
❑ Las owncr.fthe Property,amexedusively contracting with limnsorlomaracmnm
construct the pmject(See.?DW,Business and Profexime Cade:)The COMon"cra PERMIT ISSUANCE
License Law docs not appl y m an owner of property who builds as improves Lemon,and
who conte.eH fm such pmjecuwith.amdactm(s)licensed purauanttothe Contractors ALTER-DRAIN&VENT.WATER(EA) FEESUMMARY
License Law. SID
C] I ma exempt under Sec. B&P C for his reason BACK FLOW PROTECT.DEVICE SANITARY Y N-
RECEIPT#
Owner Data DRAINS.FLOOR,ROOF,AREA.COND. SCHOOLTAX Y N__
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑ Ihexby effrtn thatlhaveecmi0cate af<onxm to self-insure.oraanificate of FIXTURES-PER TRAP PARK FEE YN
Workers Compensation Wumncemscenifedcopytereo((SW-38M.1ab C.)which RECEIPT#
covers all employee'.under ria permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Policy#
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCH[CK FEE
❑ Certitiedcopyisherebyfumishcd.
❑ Certified copy is filed with the city inspection division. GREASWINDUSMIL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF RXEMPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not W completed ifrhe Permit is for one hundred dollars(SUM) SEWER-SANITARY.STORM EA.2WFT. ENERGY FEE
or less.)
I cavity that in the performance of the work for which this permit is issued,Iehall WATER HEATER WNFNT/ELECTR PAID
Ma employ any person in any manner so as no become subject m the Workers' WATER SYSTEMfrREATING Data Receipt#
Compensation Lawsof Califomia. Data
Q 'z' Apphcom NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
NOTICETO APPLICANT:if,after making this CMifite caof Exemption,you should
tz.. Taj became subject to the Worker,Compemation Provisions ofthe Labor Code.you must BUILDING FEE
K. forthwith comply wit such provisions or this permit shall be deemed invoked.
W QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm tat there is a conavuction lending agency for the performance of TOTAL: ELECI'WC FEE
u 0 to work for which his permit is issued 1Su.309],Civ.C.)
U. Lendds Name QTY, - MECHANICAL PERM IT PEE PLUMBING FEE
O Lenders Address Me .:
1 certifyfy tat 1 have read this city
and application and stem that the above information e. MECHANICAL FEE
>" L2a correct.!agree to comply with all city and county oNinancee arm sum laws inlatingm PERMIT ISSUANCE
V a' building construction,and hereby amR OR ADD TO MECH.horiu representatives of this city to enter upon the CONSTRUCTION TAX
above-memi.ned property for inspection purposes. AL'fL
(We)agree to save,indemnify and keep harmless the City of Cupertino against AIR HANDLING UNIT(TO 10,000 CFM)
lubilities,judgmenu,costs and expenses which may in any way acme eg.I.,said City
inw ce of the granting of tis pe 't. /9 AIR HANDLING UNIT(OVER------CFM)
Signe re of APPlicanVContmaor Dote EXI IAUST HOOD DVIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IWAs)BTU) Data Receipt#
Will the do opens fuumicipal Coca,ng hula ,9.tore o.handle Health andncestuous Salm HEATING UNIT(OVER IW,gp BTU) TAC:
x defined by the Cupertino Municipal Code.Chapter 9.Q,and to Health end Safety
Coda,Section 25532(.)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No ISSUANCE DATE
BOILER-COMP(3HP OR I W,000 BTU)
Will the ucontamtur inants-1 building by the Bay Are.Air Quality
ich gemeit pp
i • hazamtlaus air contaminants es defined by the Buy Areu Air Quntity M.negemcnt BOILER.COMP(OVEH IW,IXIO BTU) r a I D
DiMiD? y�
❑Yes ❑No NEW RESIDENTIAL MECH, gQ.M.
1 have read the bssardeas materials requitement.under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that Cq
if the building does not currently have a tenant,that it isery responsibility to notify the
cupant of the requirements which must be met prior to issuance of a Certificate of
occupancy. TOTAL:
O,a.,,mamhodxd agent - Data
TOTAL: ISSUED BY:
OFFICE