26513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PF.RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - C O
BUILDING PROJECT IDENTIFICATION J J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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I1NITp LOTH G ,
OWNPR NAME' B: ONTROL#
CONTRALTO 'g NAME: LIC NO:
l - NIC C
RCHITECT/ENGINEER: LIC NO:
CONTACT': _ PHONE: Ar-u4 S L ^ y :.
pTY. gx# ELECTRIC PHRM[T; k r E ' - BUILDING PERMIT INFO
���sa ((��•• s". '. %!b' at l,fID lZ is sen 4 -•{t •BI,pG EL� PLUMB MECH
(/� 0 _ �� O PERMIT ISSUANCE 1'tWf'-' El 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
py^z Iherehya Division an 3 ofth sed Business
and rifesio Ch Circle,
it(commencing with �� 6k L/ �
FOO Section mmy.rDivision Sof the Business end Professions Coda a(c my license is in PANELS
Hill force arta effect. '•✓ A .
ce VZ VjD License C Lic.# S�`y J UP TO 200 AMPS' tpA4I /zoo 4^
,Fir a'y Date Cmnf+a^m,.AH< ' /Cu/gt
�r�[' 201-1000 AMPS
Z FON7a ARCHITECTS DECLARATIONOVER I"AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plans shall be used as public records.
rt.k W SIGNS ELECTRICAL
Licensed Professional
Efi OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
y Op, I hereby affirm that I an exempt from the Coatractues License Lew for the
W t V.y following mason.(Section]03 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Oce which requires a permit tm construct,elect,improve,demalish,or repair any structure
}�
Poor to its issuance.also requires the applicant for such prennift to file a signed statement POWER DEVICES
W Aa that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter
e lr. 9(commencing with genion]000)oFDivision 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC �a5f VALUATION
a
to or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �` —
tio /1 ^'
6 Secn]031.5 by stay applicant fora permit subj.%the applieunf m e civil penaltyof
not more than rive hundred dollars($500). Q STORIES TYPE CONSTRUCTION
K p ❑ Lasoorrk,atheproperty,ormyemtendad Offieegesasthei(Sm.comprnsiness
NEW RESIDENTIAL ELECUR S .FT:
y3°y will dofhewons Code:
Tis Cutaneous
mis License
afw does rside not apply to an Business
and Professions Cade:The Conther on.License Law does not apply ll an owner of
propertywhobuildsorimproves thereon,and whodoessuchworkhi offe or fv ale.his
ownOCC.GROUP RES.UNITS
howemployebuilding
u p ing orimpr suchen rovementhin notiearofo proffered for sale.If,
however,theeavete burden of mem issoldhe did but
eyed of completion,theosse of TOTAL:
sale). ill have the burden of proving that he did not bmld m improve for puryo of
re � . ,
a❑)l,asowneroftha luovd traefin Nliwnsedc..o-.ctonto QT,Yt °- vPLUMBING PERMIT, FEE FLOOD—ZONE APN
pm.7014,Business
ywn 6w1 ,d. F*-.4
onswn the pmjed(Sec.91N4,Business and Professions Cadep The Contractors PERMIT ISSUANCE
License Lew Jas not apply to an owner of property who budds;or improves Hereon,and
who contracts forsuch projens with acontracmr(s)licensed purauant mfhe Contractor's ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 nm exempt under Sec. ,B&PC For this reason IIT ES
BACK FLOW PROTECT,DEVICE ITARY Y N
Owner Date DRAWS-FLOOR,ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHO Y N
❑ I hereby affirm that l have a certificate ofemsentto self-insure,ore certificate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation lnsumnce or a certified copy thereof(Sm.380,Lab CJ which RK FEE Y N
covens all employees under this permit. GAS-EA.gYSTEMd INC.40IITLETS RECEIPT#
PolicyY BUI GDIVISION FEES
Company GAS-FA.SYSTEM-OVER4(EA) IANC KFEE
❑ Certified copy is hereby hammed.
med.
❑ Certified copy is filed wit to city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR ARADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed not be completed lithe permit is foranehundred dollare($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfromence of Ne work for which His permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any member so as m become subject to He Workers' PAID
Compensation Lawsof California. Date WATER SYSTEMITHRATING Dare Receipt It
Applicant _
0 NOTICE TO APPLICANT:If.after making this Cietificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(q become subject to He Workers Compensation provisions of the Labor Code,you must
�i
forthwith comply wit such provisions or His permit shall he deemed revoked. BUILDINGFEE
Lgl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O
1 hereby affirm that there is a construction lending agency for the psrfofinence of
U O FE
TOTAL: ELECTRIC E
the work far which this Femur Is Issued(Sec 3097,Civ.C.)
w Lrndela Name QTY 2' M8CN9NiCALPBRMIT r ' `EBB- - PLUMBING FEE
Lenders Address
O W 1 minify that 1 have reed this application and mine that the above information is �I" A MECHANICAL FEE
toren.I agree to comply with all city and county ordinances andame laws relanngm PERMITISSUANCE
Cn building wnswetion,and hereby authorize representatives of this city to enter upon the - CONSTRUCTIONTAX
U above-menfioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and map mordent the City of Cupertino against
liabilities,judgmenrs,co? dexp fseswhicl s ,arty way accrue Vit Ciry AIR HANDLING UNIT(TO 10,00)CFM)
in consequ o e the things
A ANDLING UNIT(OVER to,"CPM)
Signature of A sang nmye ace E AUST HOOD(W/DUCfI PAID
HAZA US MATERIALS DISCLOSURE HEATING UNIT(TO 104000 BTU) Dam Receipt#
Will the app]icoal o ufurebuilding occupant store or handle hazadous material HEATING UNIT(OVER IW,WOBTU) IOTA I D
as defined by the Cupertino Municipal Cade,Chapter 9.12,and He Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE REBID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) UAINCEIDATE
Will The nppmmit orf um re building by the Bay Area i,Qmliit,Man gement �JJ
1,ermines air cmntaminenfa as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTG) '
Ditldct? :q
❑Yea 11 No NEW RESIDENTIAL MECH. SQ.FT, JUN 3� t(�a7 ao(��
7
I have reed the hazardous materials requirements under Chapter 6.95 of the CITY
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand Hat yl' 1 (Jr UUI'�.M 111
if the building does not currently have a tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owneroraalaril dagent Date TOTAL: ISSUED BY:
OFFICE