26481APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO - - BUILDING - ELECTRICAL. I PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL. 26481
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BUILDING PROJRCI IDENTIFICATION L v
UNIT#
1e1:lIIIF.(l l/LIVli1fICLN;
IAC NO: AUURYgS:
❑
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NTALT: PHONE: i a'- "
Ty.,;j,Ly 4 ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG LE PLUMB MECH
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PERMIT ISSUANCE /
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
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I hereby affirm Nat l am licensed underpmvisions of Chapter9(commencing wish
Section 70010)af Division Sof he Business and Professions Cafe, and my license is in PANELS
/p /y
Fs�-i00
RUE
fall (time and effect.
UP TO 200 AMPS
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YY
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Ureme Class Lic.#
Dam Contractor MI -1000 AMPS
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1-y Z_
ARCHITECTS DECLARATION
SQ. FT. FLOOR AREA
HSQ. FT.
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I understand m hell be used as public records. OVER 1000 AMPS
YPunse
SIGNS ELECTRICAL
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Professional
OWNER.BUILDER DECLARATION SPECIAL CIRCUITMISC. MAJ
PaLicensed
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I hereby affirm at 1 mn exempt from Count CounLicense law for the
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sy
following reason. Section 7031.5, Business and Professions Code Anycitymaumy TEMP. METER OR MIX FIST. FD
which require a Permit to construct,construct,Blur, improve, demolish, m repair any'nommre
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ER
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pnortoils issuance, also reclaims me applicant forsuch permit to file a signed statement POWER DEVICES I
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that he is licensed pursuant to the provisions of the Concessions License Law (Chapter
VALU TION
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9(comm[ruing with Section 7") of Division 3 of the Business and Professions Code) SWIMMRJGPOOL F.LF.CIItIC
Moo
.,,hot he is exempttherefrom and the basis for the-Ilegedexemption. Any violation of
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ETS -SWITCHES -FI%TU
aTUn
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t for a permit subjects the applicant so acivil,artery of ---'
Section ?031.5 by y applicator O
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not arc to five hundred dollars (55013).
I,mowneraHhepmpmy,ormyemplayeeswith wageasthei...lecompemation, NEW RESIDENTIAL ELECTR_SQ. PT.
STORIES
TYPECONSTRUCTION
Rai—will
ll hewark,and Nes"ctmisnmimendMoroffer fmule(Sec.7W.Bwimss
and Profnssim ; Code: The Coruscate. Liana Law does not apply to not owner of
property whobuildsorimpmvesthereon,anlwhodoes such workhfmselforlluough his ,
OCG GROUP
RES. UNITS
own employees, provided Not such improvemename nmimmrdedorofferedforule.If.
however, the building or improvement is sold within one year of complems ,the owner- TOT
builder will have the burden of pmvih, thin he did nm build or improve for purpose of
'
'w"',
[II,wownerofthepmpeny,ameaclu4velycanwtingwithlianud connactamm QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
construct the project (Sec. 9044, Business and Pmrariians C.&:) Tom Co mrsubm's
'
Licenses.owdmsnotapplywmownerofpmpnywhobuilds mimprove Nertoryand PERMIT ISSUANCE
whocontmcs for such ryojectswidt a conlrutons)licenced pursuanpothe Connuclaes
License pLT1iR-DRAIN&VENT-WATER TEA)
Law.
FEE SUMMARY
❑ I sin exempt under Sec. , B & P C for this reason
OUTSIDE FEES
BACK FLOW PROTECT. DEVICE
SANITARY Y N
Owner Dme
RECEIPT
COND
WORKMAN COMPENSATION DECLARATION DRAINS- FLOOR, AREA, , .
SCHOOLTAX YN
RECC1PTx
❑ Ihertby affirm there hevevicenificme of wnunuo self -imam, arecenificam of FIXTURES - PER TRAP
PARK FEE Y N
Vinkers Compensation Insurance macetiGedcopythemaf Bac.3800.L-b CJwhich
vers ullempinyee's undenhis permit GAS - EA. SYSTIiM-1 INC. 40I1TLET5
Policy p
RECEIPTx
BUILDING DIVISION FEES
Company GAS - EA. SYSTEM -OVER 4 (PA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GRADING FEE
❑ Emitted copy is filed with the city inspection division. GRPASFJINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE&SETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
This section nand not becompletad Tire permit is foranehundreddollaa($IN) SEWER - SANITARY - STORM FA. 20017T.
or le
ce of thaw Permit iseued.lshall WATER HEATER WryENT/ELECIR
Ir rtify that ihe n
idormv M
M 10
nm employ any penin in any mama! so as to become ubjeet so she Wohm%
PAID
Compensation laws of Celifomia. One WATER SVSTEM/IREATING
Dv¢ Receipts,
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Applicant
0
NOTICE TO APPLICANT: If, after making Oil CenfRute of Exemption. you should NEW RESIDENTIAL PLM B. SQ. FT.
TOTAL:
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become subjauo the Workers Compensation Provisions of the labor Cade, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE
SEISMIC FFE
aQ
CONSTRUCTION LENDING AGENCY
ELECTRIC FEC
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Iheuby affirm Nat there is a consauction lending agency for me performance of
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the work for which this pemm is issued (Sec. 3097, Civ. C.) TOTAL:
Leaders Name
pF
_
Lenders Addreax QTY;.. MECHANICAL PERMIT FEE
PLUMBING FEE
CJ
I certify Nat 1 have read this application and sou Nal she above information is -
MECHANICAL HE
0.
cortcel. l agree to comply with of city and county ordinances and sate laws renting to PERMIT ISSUANCE
CONSTRUCTION TAX
construction, sural hereby aulhodu representatives ofthis city to enter upon the
Gbuilding
7
above-mcntioani property for ivpation purpose. ALTER OR ADD TO MECH.
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(We) .gree ve, indemnify and keep harmless the City of Cupertino against
liabilities, ju ,toss expense inch ' sn eyaccrueagairassvd City AIR HANDLING UNIT (1010,000CFM)
intoes the ngo hi it.
AIR HANDLING UNI'r(OVP.R 10,0130 CFM)
as
PAID
Sig r f ,plica ontmcmr Uaan EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU)
Data Receipt It
I TOTAL:
Will the applicant or future building recreant store or handle broducrus maarid HEATING UNIT (OVER I MOM BTU)
as defined by the C,ar ino Municipal Code, Chapter 9.12, and We Health and Safety
Code, Sectio 25532(-)? VENTILATION PAN (SINGLE RESID)
❑ Yes ❑ No
ISSUANCE DATE
Will heapplicantorfuture building occupant usecquipmcmordevices whichant BOILER- COMP (311P OR 1W," BTU)
'
hnuNous air comominans as defined by the Be, Arco Air Quality Management BOILER - COMP (OVER 100,000 BTU)
isnim?
1111g—
Yes No NEW RESIDENTIAL MECH.—SQ. Ff,
//�kk un
A
I have read the havrmus materials requirements under Chapter 6.95 of the
California Health&Safety Code. Sections 25505,25533 and 25534. Iunderswndthm
JUN �a
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ly have a the
responsibilitynounc
icupaire ilofthng e net, Iharior
'e
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A�
nsnolcunts ofenocfy
occupant of she requiremenu which moil be m[I prim to issu-ria of a Certificate of
whihmust to
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D -[apes -y.
If,
Ownermauthonzed agent Data _ - _ TOTAL:
ISSUED BY: