26664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
I B - ECI'RI AL PERMITNO.CITY OF CUPERTINO PLUMB SIG
BUILDING DIVISION APPLICATION/PERMIT TIICAL
BUILDING PROJECT IDENCATION
26664
BUILDING ADDRESS: ` Q S SANITARY NO. APPLICATION SUBMIITALDATE
s \` 9,6 , UNIT# LOT# S--A10-9'C0
— y^�
OWNERS NAMP.: PHONE: CONTRACTOR'5 NAME: LIC NO: No; CONTROLN
0. ulksclaor,
CIID'ECT/ENGINEER: LIC NO: ADDRESS: ElCONTACT: y—^ PHONE: l' OS QTY.'." ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�/ BLDG ELECT PLUMB MEC
5 Mn
ao I' 'an�I &.-q,., PERMIT ISSUANCE F-1El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OoIZ I herebyaffren that l sat licensed underprovisions of Chapter9(commencing with
1400 Section 9000)of Division Sof the Business and Professions Code,and my license is in PAN
Eyg �D I
FFy W full tomes and�j'f, t. r1 r.� 111
a,2U, License Class C+— y�Lic.N o'r`✓�7 S UPT02MAMPS
y=y Date Conrra�ro. ._n_.Cx1sT0.M 201.1000AMPS
Z FOonz ARCHITECTS DEC TION OVER["AMPS SQ.FT.FLOOR AREA $ISQ.FT.
pp 1 undc tan m.plans shall be umd m lie records.
�sA W t ti� --a✓✓`—� SIGNS ELECTRICAL
6Wy<
Licensed Prosional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KWC�
u I hereby affirm that I am exempt from the Contractor's License law for the
W36.y following remmn(Section 0031.5,Business and Professions Cade:Any city ormanty TEMP.METER OR POLE INST. Q
t�.1 which requires a permit to construct,alar,improve,demolish,m repair any structurestructureM A (J (s 0 1.7.1(]Q76
y'N1g prim to is immua.also requires the applicant for such permit a signed satement POWER DEVICES
�1 Op Nat he is licensed pursuant the provisions ofthe Conam es License Low(Chapter ....a I
0.p�'- 9(commencing with Section")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC U I I I VI V.-AL'VATION
,Moo or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OITFLETS-SWITCHES-FIXTURES J
t Z a Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty of
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not more than five hundred dollars(5500). NEWRESIDENTIALELECTR _S
C1I,mownernfihepmp M,ormyemploymswiNwagesmtheirmlecompematiom, STORE, TYPE CONSTRUCTION
y _ willdothe work,and the structure ismtimendedoroffered forsele(Sm.'l04q Business
and professions Code:The Contractor's License Law does not apply to an owner of
property w ho bis ilda m i reproves thereon,and who dons such woh hi mself or dam ugh his
ownemployees,provided Not suchimpmvemema a mnotimendedoroffered forsme.If, OCC .OUP RES.UNITS
however,the buildingar improvement is sold within one year ofcompletion.the owner-
builder will have theburdenofpruvierg then he distant build ornames,forf TOTAL:
pis po 0
le.).
❑ I,mowneroDhe proarty,not eaclusivelycOntraning with licensed cOntrvcmn to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the pmjmt(See.7041,Business and Professions CoAe)The Contractor's
License Luwdossnotapply town ownerofpsopeny whobuildsorimpmvmthemon,and PERMIT ISSUANCE
whocont.cts forsuch pmjecr with acontmctor(e)licensed pursuant to the Contmcmra
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I stn exempt mnJcr Sec. ,B&P C for Nis reason nlybrm
BACK FLOW PROTECT.DEVICE SANITAR', ' O Y N
Owmer Dace DRAINS-FLOOR.ROOF,AREA.COND. RECF.IPF#
WORKMAN COMPENSATION DECLARATION SCHOOLTIX Y N
❑ Thereby affirm that l have a certificate ofcoment to sel6insum,or a certificate of RECEIPT#
Worken'Cwnpcnvtionlnsu.me0n ttnifiM copy Hereof(Sa.3g00,lab C.)which FIXTURES-PER TRAP PARK I:f.E Y N
rove.ell can is p�nit. �s� �q GAS-EA.SYSTEM-I INC.40I1TLE1'S - RECEIP`#
Policy p 4] V('/ SC :&P `lO BUILDING DIVISION FRES
�{
4-Certified copy GAS-EA,SYSTEM-OVER 4(EA) PLANCHECK is hereby furnished. FEE
❑ Cenified copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rad not bemmpleted ifthe permit is foronehundrN4ollan(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for whichthix permit is issued,label WATER HEATER W)VENTIELECTR
not employ any Person in any manner so as to became subject t0 the Workers PAID
7-. Compensalicut awsof Celifomia. Dam WATER SYSTEM/fRFATING Date Reccipt#
Applicant
OQ NOTICE TO APPLICANT:If,after makingthis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
pdOn,y TOTAL:
y become subject to the Workers Compensation provisions of the Labor Code,you must
ah foNtwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Z CONSTRUCTION LENDING AGENCY SEIS! 'C FEE
Ft I hereby affirm that herc iso combustion lending agency for the pinfermance of
V O the work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELCC9 IC FEF:
Lenders Name
Q U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMoo K3 FEE -
I certify thm 1 have most this application and state that the above information is
cret. MECHANICAL FEE
0. g
y building construction,and hereby authorise minesenmtivesofthis city mentcrupnn the CONSTRUCTION TAX
t,1 7-. above-mentioned property for inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,indemnify and kcep formless the City of Cupertino against
Iiabilities,judgmenu,costs and expenses which may in any way uccme against said City AIR HANDLING UNIT(TO 10,004)CFM)
in crosequence of the gmnting of this permit. I
AIR HANDLING UNIT(OVER 10,000 CFhp
Signatureof ApplicamgCom.cmr Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CFO 100,000 BTU) Dam RmeiptN
Will the applicant or future building occupant atom or handle hazardous material HEATING UNIT(OVER 100,IXN1 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)P
❑Yea 13 No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will the eppliunmrfuttuebuildingoccupantuueyuipmcnlordevices whichemit HOMER-COMP(3HP OR I00,000 BTU)
harmous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
UIaViC14
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the harardous materials requirecomrs under Chapter 6.95 of the
California 11.111,&Safety Code,Sections 25505.25533 and 25534.1 understand that
if the building does not currently have a meant,that it is my responsibility to ratify the
occupant of the requirements which must be met Prior to issuance of a Ceerlficate of
Occupancy.
Owner or authoved agent Dam TOTAL: ISSUED BY:
OFFICE