26527 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHUI. '- I PERMITNO.
APPLICATION/PERMIT PLUMB NG '--NG.-MECHANICAL n C 2rI2
BUILDING DIVISION BUILDINGPROTEO:T I I)ENTDTCATION L5
BUILDING ADDRRIESS: ./ SANITARY NO. APPLICITIONSUBMITTALDAD
0.7-TStJ� S /,- UNIT# LOT#
OW ERS NAME: PHONE,: CONI RA NAAE: LICNO;
ENE ESI 2 S 33 - Y1 N/C CONTROL#
1RCHITECT/ENGINEER: OOC7bot»LIC NO: ADDRESS: ❑
2� S �•
'0 ACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L BELONG (ELECT P MF.CH
C QQ PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 100 DFSCR TION
F El
mxz I hereby affirm that l am licensed under provisions of Chapter9(commencing with
FOkYO❑ Scnioretold of Division Jof the Business and ProfessionsCWc,and my license is in PANELS
aUU lull fore told cfleet. "�ggc� l (`1Fy)-
IQ„Z.u1 License Cluss B lisp 3S1O6 / � UP TO 20)AMPS 1
rnQh Sce Coem un 201-1000 AMPS
ZOyZ ARCHITECT'S DECLARATION OVER IOWAMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1 understand my plans shall be used as public cereals.
r y C W SIGNS ELECTRICAL
Q f J Licensed Professional
ee=ceQ OWNER-BUILDER DECLARATION SPECIAL CIRCUTSMIISC.
XO a F 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
m 3 a rn following reason.(Section]031.5,Business and Professions Code:Any citym county TEMP.METER OR POLE INST.
F"Ir0< which reyuires m permit m emoma,el¢r,improve,demolish,or repair any structure
ggg�r��r..I'IY� prior b)its issuance,also requires the applicant for such Permit o lilt a signed statement POWER DEVICES
K GD that he is licensed purxuant to the previsions of the Contractor's License Law(Chapter J I' r L=.• Lr• r
e� 'l lh Section9000)of Division3ofthe Businessland Professions Code) SWIMMINGPOOLELECDE .
(commencing wt Flil tS e VALUATION
Wimor he is exempt thereftmn and the basis finds,alleged exemption.Any violation of
F-Za Sation 903 LS by any applicant!mapetmit subjmts the applicant to a<ivil peeWry of OUTLETS-SWITCHES-FI%TtIRES(
E 2 not mom than five hundred dollars($500).
caro ❑ Lasownerofthe PropenYoemyemployeeswithwagesasthcirxlecampenxuon, NEW RESIDENTIALELECTR SQ,FT. STORTIESI TYPECONSTRUCTION
L
will dome work,andthe structure is not imeadedoroffered farsale(Ses.9040,Business J
and Professions Code:The Contractor's License Law does not apply to an owner of 1
Property whobuilds or improves thereon.and whodoes such work himselforthroughhis
employees,provided Staxuch improvements are not intended oroffcmd fmsale.If, OCC GR UP RES.UNITS
however,
aver ,the building or improvement is sold within one yearofcompletion,the owner- ,TOTAL.
builder will have the burden of praying that he did not build or improve for purport,of
Ic.). QTY, PLUMBING PERMIT FEE FLOOD
s ZONIi APN
❑ I.as owner oflhe progeny,an enclusivelycontracting with licensed contractors to
consmoa he project(Sec.9044,Business and Professions Codc:)The Commucrors
I.icenselawdcesnotapplytoanownerofpropenywhobuil&orimpmvesthereon,and PERMIT ISSUANCE
wMwhLicense LoLsALTER w. ( )cts fm such projects witheconnanoo(s)IiceotsW pursuvtt to the Convamolx EA FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason SIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y__N
Owner Dare GRAINS FLOOR,ROOF,AREAGOND. RECEIPT#
a� WORKMAN at
DECLARATION - . SCHOOLTAX Y__N
'W herebyaffrre Nat l have a cenifcatn
c ofcomeno self-insure,or a certificate of FI%3'URGS-PER TRAP RECEIPT'#
Worken'Compensatinn lnsuruncc orecenifed copy thereoff5ee.38W,LabCJ which PARK FEE Y_ N
covers all employee's an i spermia GAS-EA.SYSTEM-1 INC.4 OUTLETS RECF.IPTN
Policy# a#J(•- r L/s24��
Company Sr.is En tan a LTIO,*1L_ BUILDING DIVISION FEES
n` Certified copy is hereby fumishW. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is filed wiN Neciry inspection division GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF ULEMPDON FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SOILS FEE
IThis sectlon need not be completed ifthe permit is forome hundred dollars($IW) SEWER-SANITARY-STORM HA.2001`T. F,
or less.) ENERGY FE
I certify that in the performance ofthe work for which this permit is issued.I shall WATER HEATER W/VENTiELECTR
not employ any prrsen in any manner see as m become subject to the Workers' PAID
O z Compensatiom"vesof Califomia. Data WATER SYSTEMIFREATING Date; RaeiptN
Applicv
z NOTICE.TO APPLICANT.If.Mta making this Certificate of Exemption,you should NEW RESIDENTIAL PIMIL SQ.FT, TOTAL:
F V) (come subject o th
e Worker's Compensation provisions of the Labor Cade,you must
a > forthwith comply with such provisions or this permit shall lse demand revoked. C Pipe BUILDING FEE
0. A CONSTRUCTION LENDING AGENCY rt SEISMIC FEE
Uz I hereby affirm that them is a con.ehuction lending agency for the performance of
O the work for which thjs pertg�Is Issued(Sve 3099,Civ.C) T ELECTRIC FEE
Icndcr'x Namc -1 J ,
C U U Lender's Addres .'aMb t`2T 1 lf ,l Uu QTY. MECHANICAL PERMIT FEF- PLUMBINGFEE
1 certify mat T have read this application and same that Ne above inforr ation is
mFEE
rtcato. I agree comply with all city rout county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL t
F" building consuacvon,and hembyinthome repmxntativesofthia city toenrer upon the
U Z above-mentioned limitedly for inspection purposes. ALTERORADDTOMECH. CONSTRUC IONITA%
(We)agre,to save,morannify and keep ha ardois the City of Cupertino against
ludiities,judgmcnu,costs and expenses which may in any way acmueagainstsaid City A IR HANDLING UNIT(TO I0,000 CFM)
in consequence of the ting chis permit. t
AIR HANDLING UNIT(OVER 10,000 CPM)
'�'�� .a �� ,. .,A 8//
.'IOnre lit A oro/Convaemr ate EXHAUST HOOD(W/DUC'F)
PAID
HAZARDOUS MATERIALSDISCLOSURE
or ha RE HEATING UNIT(TO IW,OW BTU) Dae Receipt#
Will the applicant orfurorebuilding occupant store o,handle haealtha material
I defined blithe Cupertino Municipal Code.Chapter 9.12,and Nc Health and Safety HEATING UNIT(OVER 1 00.000 BTU) I fIrTA-1)
l Coda Satior❑Y232(a7? 19No VENDLpT10N FAN(SING LE RISID),lift BOILER-COMP QHP OR 100.1100 BTU) ISSUANCE DATE
Will the a con coronas building by the Bay Ana
nrdevic Man igeme it ,fA O ,sea
ta'vic'? air comaminava as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.0110 BTU) #'4 6t yi
islricR ❑Ycs 14 No AUG
NEW RESIDENTIAL MECH. SQ.FT. r A
1 have mad the numerals materials requirements under Chapter 6.95 of the Y 199q
Culifomialloalth&Safety Coda Sections25505,25533end25534. Iunderstand Nat oil I, Ur
if Ne h tilding does not rancidity have a ream,that is is my responsibility a nmify the
ecupant of she requirements which must be,mea prior to issuance of a Cevlfiam of Urtrl I IIS(f
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE