26342 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO N II,DL G-ELECTRI AL PERMIT NO.
APPLICATION/PERMIT PLUMB ING-MECHANICALn�+ /� s$ ;
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G U J 4 e
BUILDINGADDRESS: r� 1_ SANITARY NO. APPLICATIONSUBMTITALDA'11
iJ
//,;12 �� J 7 �.O UNIT# LOT#
OWNERS NAME: PHONE: NT CTOR'S NAME: LIC NO: 7
ve- N/C CONTROL
• 11 ECI'IENGINEr LIC SKY KESS:
Q
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRI N
po4Z I hereby affirm that l am licensed under provisionxofChapler9(commencing with
+1 100 Section 7")of Division 3 of Ne Business and Professions Cade,and my license is in PANELS
=w— full farce and effect.
<7W Licenx Class Lie.If UP T0200 AMPS
PRZ
w<ar Date Contractor 201-1000 AMPS
Z065— ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.I OOgARF i $/SQ.FT.
OZ— 1 land mY pl. Il be blit records. �I��o
ftnF, SIGNS ELECTRICAL 1 IM �,
Licensed Professional
.. fes'
ye. OWNER-BUILDER DECLARATION SPECIALCIRCUIDMISC. 1 SII la tl
N1 hereby aRrm that 1 am exempt from the Conlmnors License Law for he l
613¢-vFi fallowing mumn.(Section 7031.5,Business and Professions Code:Any city or coumy TEMP.METER OR POLE INST.
I which requires a Permit o connroct,alter,improve,demolish,or repair any structure
�o ATE prior to its issuance.also requires Ne applicant forsuch permit to file a signed statement POWER DE VICESF1 In J
d 0 that he is licensed pursuant m the provisions of the Contractor's License Law(CTapmr SWIMMING POOL ELF,CTRIC
aaoT 9(commencing with Smfon]0W)of Division 3 er the It usiness and Professions Code) - — VALUATION
or he is exempt therefrom and the lack for the alleged exemption.Any violation of OUTLETS I'S-SWITCHES-FIXTURES
F7Q Section 7031.5 by any applicant for a peoni t.subjects the appl icant to a civil penalty of
SSD not more Nan five hundred dollars($5010). NEW RESIDENTIAL F.LIiCfR _SQ.FT.
CFo ❑ I,asowncrofthepmpeny,army employees with wagesastbeirsnlecnmpensufinn, STORIES TYPE CONSTRUCTION
a3= will do the work.and the structure is not inlendedarorfereA hostile(See 79J4,Business
and Professions Code:The Contractor s License Law does not apply to an owner of
property who builds or improves Nemon,and who does such work himself or through his
employees,provided that such improvements amnot inlendedoroffered forsale.If, OCC.GROUT' RES.UNIT'S
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
s'1l QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ I, the pr jeNe Sec.70,am Business
ss and Professions
s Codc.)Th Contemrsm
Limaeconsumer the project(Sec..On.Business and Professions Code:)The Contractors PERMIT ISSUANCE
Licenxlawdoes such
applyctanownerorpmpery whobuildsrs improves thereon,and
Lwho imme raclslnrsuch projects wiNnttmtracmr(s)licenxd pursuant the Convamors ALTER (EA)Licenx Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this muson OUTSIDE -ES
BACK BLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-FLOORROOFAREA. RECEIPT#
, . . .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm lballbavcaccrifcata.f nmunt In ulGinsurc,nraccrtifcute of FIXTURES-PERTRAP RECEIPT'#
WorkersCompensation Insurance mecmifed copy Nereof(Sec.3810,Lab C.)which PARK FEE Y N
covers all employees under this permit' GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Palmy# BUILDING DIVISION FEES
Company GAS-II.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASWINDUS'TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFAS17TRAP SOILS FEE
COMPENSATION INSURANCE
(ThisxclionnecdnotbecompletAifthepermit is fmonehundred dollars($100) SEWER-SANITARY-STORM If.21)(41'. ENERGY FEE
or less.)
I certify that in the peakwaranceof the weak for which this permit is issued,l shall WATER HEATER W/VENTfl.E(7fR
not employ any person in any m as m become subject to the Workers' PAID
ComIp,mationlawsof California. Date so WATER SYSTEM/TREATING Date Receipt#
Q Z Applicant
Z NOTICE TO APPLICANT:IL after moving this Certificate of Exemption.you should NEW RESIDENTIAL PLv B. SQ.FT. TOTAL:
1--' become suhjectto the Worker's Compensation provisions of the Labor Cale,you must
forthwith comply with such provisions.,this permit said be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
= z Iherchyaffrm that there is a construction lending agency border performance of
U O the work for which this permit is issued(Sm.3092,Civ.C.) ELECTRIC FEE
Lender's Name
OF Leaden Address QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
L) I certify that 1 have read this application and state that the above information is
correct. Ia agree to comply with all cit and ordinances and stale laws relating to PERMIT ISSUANCE MECHANICAL FEE
8 PY tui yon county g
L) z warsengcomired construction,andhercbyauthonmrcoses.representatives city mart¢,upon the CONST'RUCI'IONTAX
U '� above-mentioned to case
for inspection purposes. ALTER OR ADD TO MECH.
(We).,we nt save,indemnify and keep harmless the City of Cupensts against
liabilities,judgrncros.cwuand expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,1100 CFM) 1.
in cooseque fthe Branti ng of Or ,mit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sigtuture.f Applican .uowr r l Date EXHAUST HOOD OVDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle herardons material
as defined by the Cupertino Municipal Code,Chapter 9.12,and he l ENIth and Safe,, HEATING UNIT(OVER I W,qO BTU) IOTA
Code,Sectio.25532(a)2
❑Ycs ID No VENTILATION FAN(SINGLE REMO)
Will
ISSUANCE ATE
Neu applicant.,Tamm building ruse iceswhichemit BOILER-COMP(3HPOR 100,000 BTU)
PP Boccupan equipmcnInrdcv
rerardous air contaminants as def ed by the Buy Area Air Quality Management BOILER-COMP(OVER HIQO00 BTU) R9
Jiatncl! r
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have mad the harurdous materials requirements under Chapter 6.95 of the MAY41994
California Health&Safely Cash,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently Imve a meant that it is my responsibility to notify Ne
occupant of the requirements which must h met prior to issuance of a Cenifcale of CI I Y Ur uuren 1 u�
Occupancy.
Owner nr uuMurired ngcm Orae TOTAL: ISSUED BY:
OFFICE