26578APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO UILIANO - hLhU�7 I " PERMIT NO.
NUIFIXING DIVISION APPLICATION/PERMIT rn n,vUMBuNG4 MECxu N'L AL rrsN 2 F;.[;
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LOT# 12
ARC1111'I:CI'/FNGINEI?R: LIC NO: r � SS:�L�nfp AVC fALo A El
CONTACD HONE QTrY. ELECTRIC PERMIT FEE 1.1 ) BUILDING PERMIT INFO
8 ���ZZ• PERMIT ISSUANCE RLD.9 ECT PLUMB -F
�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES - RESIDENTIAL
C19z I hereby affirm 9mth that l am licensed under provisionsofChapsar(comenciagwiTOB DESCRIPTION
W�0O Section
n1 ))ofDvision Sof the Business and Profession,, Cock, end my license is in PANELS
aUg I.icrnse Cl I.ic.p ��Z 1� UPT0200AMM
vFiay pate Contractor Is II 201 1000 AMPS
F A HITECI'S DECLARATION SQ. FT. FLOOR AREA 5/SQ. FT.
Z0'3 OVER ELEC RIC
O Z"� I understand my plans shall he used as public records. �wQ
Fy SIGNS ELECTRICA. W(,�,
Licensed Professional 1
OWNER -BUILDER DECLARATION SPECIAL CIRCUIT/MI-
xx04 V I hereby affirm that 1 sm exempt from the Contractor's License Law for the j__If/9�J 5}J a/+f•.J,;
W 3 a vFi following reason. (Section 7031.5, Business and Professions Code: Any city nr county TEMP. METER OR POLE, INS
f.1 which requires a permit to construct, alter, improve, demolish, no repair any someone
Y� prior to its issuarre.horequires the applicant forauch pematim Blea signed statement POWER DEVICES
p that he is licensed pursuant to the provisions of the Contractors License law (Chapter
ado 9(commerem, with Section]000)of UivisionJof Ne Business and Professions Code) SWIMMING POOL ELECTRICqVALUATION.
P
Moo milhatheisaxempi thetchord and the basis for the alleged exemption. Any violation of OUTLETS -SWITCHES -FIXTURES
Z 4 Section 1031 S by any applicant for a permit subjects the applicant m a civil penalty of L
not mom than five hundred dollars (5500), fn t
SaFO ❑ I,esownerofNeproperty.ormyemploytts with wages us Neirsolecomparion e, NEWRESIDPNTIM FLECIR I41S SQ. FT. 5, STORIES TYPE CONSTRUCTION
63� will do the work, and the structure isnot intended moffered for sale (Sec.]f144, Business
wd Professions Code: The Contmcmr's License law does not apply to an owner of
pnpenywhobuildsorimproves Nemm,andwhodaessuchworkhimselforthmughhis OCC. GROUP RES. UNITS
ownemployces, provided that such improvements ere not intended m offered frorule. If,
however, the building or improvement is sold within one yearofcnmpletion, the owner- TOTAL: /�'� %j
builder will have the burden affirming that he did not build or improve fm puryose of
role.).
❑ I, us mm
ownerofthe ppmy, aexclualvely contracting with licensed contrectorvm QTY, PLUMBING PERMIT FEEFl.00D ZONE APN
construct the project (Sec. 7044. Business and Professions Codm) The Cianabourea PERMIT ISSUANCE q
I.icensel,owdoesnotapplytonnownemfpmpenywhobuildsorimpmvesthemon,end {�
whnmmmaa fm such Projects with oconuactor(sHimmoripursuaelRide Conlractoes ALTER - DRAIN&VENT - WATER EsO FEESUMMARY
License Law.
❑ 1 an, exempt under Sec. , B & P C for this rtman BACK FLOW PROTECT. DEVICE O S .
SANITARY Y _N
Owner Date RECF.IPTN
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
•❑cra'Coa,mostionInsrance ora certified
consernmselfdnsure,m Lab Cfi which FlXTURCS-PF.RTRAP RFCF.IPI'p
Wvenal Cmployeesnler daiseorecenified copy thereat(Stt.3800. LabCJwhich PARK FEE Y_N
covers all employee's ander Nis permit. GAS - EA. SYSTEM -1 INCA OUTLETS RIVISI1' M
Policy p DIVISION BUILDING DION PEES
Company GAS - EA. SYSTEM OVER 4 (EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
I ❑ Ccnificd copy is fled with the city inspection division. OREASHIINDUSTRL WASTE INTERCEPTOR GRADING FEE. 7, Lvt
C17R'I'IFICA'I'E OF 17XEMMON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section readout becompleted ifrhe permit is Intone hundmddollar,(SIM) SEWER- SANITARY- STORM P.A. 200FT. ENERGY FEF. w
orless.)
I certify that in the Performance ofthe work for which this permit is issued,) shall WATER HEATER W/VENT/ELECTR
not employ any Person in any m as to become subject m the Workers' PAID
Compensation Lawsof California. Dare so WATER SYSTEMUREATING Date Receipt
Z Applicant
Z� 0 NO] ICE TO APPLICANT: If, after making this Certificate of Exemption, you should NEWRESIDENTIALPLMIF MIS SQ. FT. /dts7j'iJ p
!—I p] become subject to the Wader's Compensation provisions of the labor Code, you must
; forthwith comply with such provisions or this Permit shall he deemed revoked. BUILDING FEE ur s
L2I q CONSTRUCTION LENDING AGENCY SEISMIC F'HF 3�
�1. � ELECT? 1 hereby affirm that there is a construction lending agency for the performance of n
U z oE 43
O the work for which this permit is issued (Sm. 3091, Civ. C.) y' -I
TOTAL: r
Lender's Name PLUMBIN
Lender's Address QTY. MECHANICAL PERMIT' PEE �
0 L) I certify that I have read this application and state that the above information is 2
�"t I3I correct. l agree to comply with all city and county ordinances and state laws relating to FERMI'I ISSUANCE n -4 MF.CIIANI LFEC 9
building construction. and hereby authnria, representatives of this city to enter upon the L CONSIRU TAX
L) z above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
i --t (We) agree m save, indemnify end kap handless the City of Cupertino against
liabilities,judgmrnu. emu and expenses which may in any way acerueogaina said City AIR HANDLING UNIT (TO 10,W0 CFM)
in onndeqm h�no f Jh L
tkAIR HANDLING UNIT (OVER OAIXCFM)
Sig
m4/D e EXHAUST HOOD(W/DUC
a o Appiicamctor
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT LTD 100,0001 BTU) late tprp
Will the applicant or future building occupant store or handle haafdous material
as claimed by the Carinthia Municipal Code. Chapter 9,12, and the Thedth and Safety HEATING UNIT (OVER 100,000 BTU) TOTAL:
Code, Section 25532(a)? VENTILATION PAN (SINGLE REMD)
❑ Yes ❑ No
BOILER - COMP QHP OR HILL" BTU) ISSUANCE DATE
Will the ucont a contaminants
rfmurebuiined by the rise rat Ainwuality Management rsa A I
hazeNoux air comeminans as defined by the Bey Arca Air Quality Management BOILER - COMP (OVER If10,f10) BTU) �}+
District?11
Yes ❑ No NNW RESIDENTIAL MECH. SQ. Fr'. V ra y
1 have read the leaurdous materials acquirements under Chapter 6.95 of the NOV 2 3 1994
California Health & Safety Code, Sections 25505, 2553] and 25534. I understand that
if the building does not currently have a tenant, hat it is my responsibility to notify the C11Y ut VUYCIiI IIYU
occupant of the requirements which must be met prior to ismance of o Certificate of
Occupancy. .
Owner or soluind agent _ Date TOTAL: �',3 ISSUED BY: