26801 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- - PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
1.
BUILDING ADDRESS � SANITARY NO. APPLICATIONSUBMITTAALLDATE
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LAV-P" `. NITN—
LOTS
OWE; MF.: // a 25 PHONE: O CQpq' o O//�JS rrP Z�/fy(.y 6S NAME: LIC O: rvrc CONTR
ARCHITELT/ENGINEER: LIC NO: Arj.1PJR/u¢g. V
:,4_
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y/VT• wav 9954
CONTACT: PHONE: QTY"ti;;, ELECTRIC PERMIT .FEE BUILDING PERMIT INFO
BLDG ELECTP UMB MECH
PERMIT ISSUANCE 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION
pp.Z I herchyafron that l am licemedunderprovisiooafChap,cr9(coonencingwiN
�a1O0 Section 700))of Division 3 of,he Business and Professions Code,and my licrnu is in PANELS /1
�u� uieo eand eBeet.CV GSA UP TO 200 AMPS
zz Lic.#
In 6 6 Dole Camua-r 201-IOW AMPS
ZOyr' ARCHITECPSDECLARATI OVER IOW AMPS SQ.PI'.FLOOR AREA EtSQ.PI'.
O Z� I understand my Plms shall be used as public records.
aSIGNS ELECTRICAL
J.y Licensed Profeut...I
04 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
NOV I hereby offinn Nes T an exempt from the Committee,License law Ins Ne
D130 no following mason.(Section 1031.5,Business and Professions Code:My city or county TEMP.METER OR POLE MST.
o,Oa; which requires a p<miit to c-nstma,aha,improve,demolish,or repair any structure
�yM primmiiummuce,alsorepriresthttiolicautf.ramhpemNmfileasinintisenmm POWER DEVICES
ap that he is licensed pensionno the provisions of the Contreem's License Law(Chapter
Ly❑ SWIMMING POOL ELECTRIC VALUATION
X� 9(commeis(commencing Section Rl00)oe basisian3e(Needexemand, My viola Cade)
til rOm or Net h70315 mpnhertfromandirloo ,sidejfor ellegedenemint-n.Myl Penson of
��N Section]WLS by unyapplicant forapermi,subjas the epphcan,macivil Penalty of OUTLEfS-SWITCHES-FTXTURFS
or
no tame Nan five hundred dollar($500).
O NEWRESIDENTIALELECIt _SQ.FT. RIES TYPE CONSTRUCf1ON
❑ othe wnerofNepscruct,n isnot PloyeeswiNwngesmd,(Selecompensadm,
OR
y will dothesimix Codeand sw Contractors
is License affend mens ul apply 1044,.1of
and nywh ns l&or The v.ffic o's License law does not apply tort owns of
pfopcnywi,eas, dvoried mo vat Nereon,nnd whoamar os such workhimflared brough his
however,mees,provided improvement
is vcmenmare not ihmndedoof(ercd brandtheow.IM, RES.UNITS
however,Ne have
the
boron
ofpment is that
he within one year ofcompletion.th purpose
of TOTAL:
builder will have Ne burden of proving Net he did not build at improve for purpose.(
awn). QTYG Y. PLUMBING PERMIT FEE
❑ I,n ownerufthe property,emexclusivelycontracting with licensed contractors to ,.,.h, FLOOD ZONE APN
commit,the project(Sur.7044,Business and Professions Code:)The Comommts
License Law does not apply men owner of property who builds orimprovuthercon,end PERMIT ISSUANCE
whocontractsfor such projects withacen,rmmr(s)licensed pormantuthe Cantractots ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
License Law.
❑ 1 sm exempt under Sec. ,B&P C for this season OUTSIDE
BACK FLOW PROTECT.DEVICE SANITARY Y_N
Owner Data— #RAMS-Pt.00R,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y—N-
I
N
I❑ Iherebyeffrm the,l have a cenifcae ofconenuo half-moons,or a cetificme of ITXTURES PER TRAP RECEIPT
Vorkert Compmeation Insurance ora certified copy therref(Sce.3800,Lmb CJ which PARK FEE Y N
covers all employees under this petni� GAS-PA.SYSTEM-1 INCA OITfLETS RECEIPT#
Policy# L BUILDING DIVISION FEES
Company GAS.EA.SYSTEM-OVER 4 EEA) PLANCHECK FMB
❑ CeniBet copy is hereby famished.
)<Cetified copy is Bled with dustily inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section nadnotbeeomplmel ifthe permit I.for une hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE '
or less.)
I certify that in dm perfomanee of the work for which this Permit is issued,l skull WATER HEATER W/VENT(ELECTR
not employ any person in any manner ao{y t_hwor�s!"don Waher% PAID
Cottonmouth omi Tye �i(O lam/ WATER SYSTEM/ITtEATING Uau Rcceiptp
00 NOTICE TO APPLICANT:if,after task g�Rthis Canifia`te of Exemption,you should NEW RESIDENTIAL PWB. SO.FT. TOTAL:
Uj become subject to the Worker Comprnsetion provision ofthe Labor Cade,you mus,
ai (rout comply with such provision or this pemdt shall be deemed revoked. BUILDING FEE
67 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for flat performance of MECRIC FEE
U 0 the wok for which this Permit Is issued(Sec.3097,Civ.C.) __rt
Leader's theme PLUMBING FEE
V.
Lenders AddressCHANICAL PERMIT FEE
0 U I terrify Na,I have reed this application and stain Nat rhe above information is ",:19.->�i<;i.7`m:a ..
Y W MECHANICAL FEE
toed.legs m end umuW
comply withal)aity ...n,milinstemewa
lrelminm gPERMIT ISSUANCE
rt
�+ U) building construction,and hereby emheriu representatives ofthiscity reenter upon the CONSTRUCTION TAX
U Z ebovemendmed property for inspection Purposes. ALTER OR ADD TO MECH.
(We)a,.he save,indemnify and keep harmless the City of Colston--&-hat
lieddlities,judgments,cosa and expenses which may many way accrueagainst said City AIR ITANDLING UNIT(TO 10,00)CFM)
in remuneration of the grunting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signore of Applicion Contmnor Data EXHAUST HOOD(W/DUCT) PAID
I A RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will,he applicant or future building oaupant stare or handle hvardom material TOTAL
as defined by Ne Cupertino Municipal Cade,Chapter 9.12,tied Ne Health and Safety HEATING UNIT(OVER IW,OW BTU)
Code Secti-n 25532(a)] VENTILATION PAN(SINGLE RESID)
❑Yee ❑No
BOILER-COMP(311P OR 100,000 BTU) p� # ISSUANCE DATE
Will lheapplicantorfumre buildingoccupanqui
tuhaepmemordevices which emit 1f- P1
hamNom air cemsminants as definal by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
grin]
❑Yes [3No NEW RESIDENTIAL MECN. SQ.FT. JUL 28 H 19%
I have read the hmardeas materials requirements under Chapter 6.95 of the
California Hermit&Safety Code,Sections 25505,M533 and 25534.1 understand that 'GIIY ser l;ur
if the building does not enormity have a tenant Nm i,is my mspersibiliry,e notify the th I INV
cupsn,of the requirements which must be met prio in issuance of a Cernfrcale of
Occupancy.
Owner or mNodaed agent Data TOTAL: ISSUED BY: