26398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUD, ;N i LLECI RICAL PERMIT NO.
APPLICATION/PERMIT PING PROD -MECHANICAL 2 6 3 9 E
BUILDING DIVISION BUILDING PROJF.CI'IUEN'pIFICATION L 3 VM }yl
xU .DING ADDRI355: 1�On/T1 SANITARY NO. /AP}PL^ICATIO/N('SUHMITTAL UATI
2Z3. � IUNITX LOT# `—� VC�EJ
Oy'NE SNA E: I PHONE: CO ACI'OR:S NAME: LICNO: J LCJ —�
t Cu ni
N/C CONTROL#
ARCHI'IECT/fifJGl EER: LIC NO: AD ESSEla
CONTACT': cry5tn4z y) l/O PHONE: r ITyp QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
'•�^'"—I JJ LUG
Ll s L_�II�Qq V— 50 PLUMB M CII
6�O0 PERMIT ISSUANCE �•
LICENSED COkOLACTOR'S DECLARATION APPLIANCES-RESIDENELETIAL ION DESCRIPTION
affirm tharlam licensed und<rpmvisi.ns.f Chapmr9(commencing with ��
tv102 Section')0p0b of Division 3 ofthe Business and Profepssions Code,and my license vin PANELS
4 fucose and cffcy. Lic.p �� / G2 UP TO 200 AMPS W
W� T
tJ License C s
t-ZW
F,Q'y Dene r " Convaemr 201-1000 AMPS
ZOy/ ARCHITECT'SDECLARAI'10N OVER 1000AMPS SQ.Pf.FLOOR AREA $/SQ.IT.
O Z—❑ I understand.,,[.,,hall becredits public record..,
y E" SIGNS ELECTRICAL
Licensed Professional
C a,yea -OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyU 1 hereby.Ifirm Mat 1 am extent,from the Commerce,License Law for the
W 3 e.ti following roman.(Section 7031.5.Business and Professions Code:Any city m county TEMP.METER OR POLE INST
I: which requires.permit to construct,alter,improve,demolish,or repair any structure
�'uu^11T� primo its issuance,also expires the applicant for such permit file a signed statement POWER DEVICES
C Oz that he it licensed pursuant to Me provisions of,M1e Commcn.r's License Law(Chapter
akoLL
9(commencing with Section 700B of Division 3 ofthe Businessand PmPossionsCMe) 5 IMMING POOL ELECTRIC VALUATION
ly_Q
Spr
ection
7031. by any
unp refrrnmnt f the Permit subjects
thedexemprion.Any violati.n of FIXTURES __V560
CiO f\ OJ�O O�
mdualeisL5byamyapplitrand tor a basis fsubjeas the aexcennu.advllpemimicif LETS-SWITCHES- el (J v
not tame Man five hundred dollars($500).
a: ce ❑ I.asownerofihepropeny,nrntyemploYteswiMwgoUtheirsolecomprnsation. NEW RESIDENTIAL ELECTR _SQ.FT. ESTORIES TYPE CONSTRUCfI06
LB'= willdethe work.and dualm tare isnot intended.roffcredfasale(Sea.7044,Business
and Professions Code:The Commences License Law does nor apply man owner of
property who builds m improves Hereon,and who does inch work himself m through his
own employees,provided that such improveenentaan not intendedorefferedfrrsafe.If. UP kFSUNITS
however,the building or improvement is sold within one yearofcompletion.rheowter-
buikerwill have the burdenofprovingthat he did nor build orimproeforpurposeof
sale).❑ I,as ownermftbe property.um exclusively contracting with licensed contractors to QTYPLUMBING PERMIT FEE ONE qpN
nmtma the project(Sec.7044,Business and Professions Cow)The Conrr.cm''s
License Lividness not applym an ownerofpmpeny whomildsor improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contractods)licerued pursuanuothe Commences
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt ander Sce. ,B&P C for His reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dale DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT#
WORKMAN COMPENSATION ECsedf.a O SCHOOL TAX Y N_
❑ Ihveby affirm Ma,l have a<ertificate oft runu.u(See.3eo cern Echich FIXTUR -PE RECF,IPf#
Workers'Compensationlmuris per accnifi copy Mcreof(Sec.Jg00, ab CJ which PARK FEET Y N
covers all employee's under this#emir. GAS- C. eTS RECEIPT
Policy p BUILDING DIION PEES
El CeY !EA. ER4(EA) PLA CITE V B
❑ Certified copy is hereby to shed. GAS
ElCer ified cony is filed the city impeminn division. OR DUSTRL WASTE INTERCEPTOR GRADIN FE S
CERT ATE OF EXEMPTION FROM WORKERS' GRP.ASETRAP SOILS IEE
COMPENSATION INSURANCE
Miller, need not be completed if the permit is for one hundred dollars($1 ) SEWER.SANITARY.STORM EA.200FT. ENERGY FEE
1 orlens) eoft
Iced tynyaat ctiepin any
so
torecomthiapcmtito issued.lince, WATER HEATER W/VENT/ELECTR
not cardperi li any Parson to any m so m to become subject,o,he orkeri PAID
z Comptn anion Laws of Calibtmia. Dam WATER$YSTEhf(fREATING Dam Recei
O
Applic ,
Y No1'IC iTO APPLICANT.If,aflenmakin this ificam of Exem shoal NEW RESIDENTIAL I'LMB. SQ.FT' TOTAL:
y become object o the Worker's Compen,aen r was of Cad,yo st
7
`onm
hwit comply with such pvi,lonon s .hal that . BUILDING ed rev. —•
c � FEE
y O CON TR DING,* Y SEISMIC FEE
y-D z 1 nen y affnm th e n is i c/�I'�ailing agency He perfmmanee of
L) O the work f. hick this xw, yb,30g1,Civ.C.) TOTAL: ELECTRIC FEE
Lender's SitL/
U.
U Lender',Add s QTY. MECHANICAL PERMIT FEE PLUMBING FEE 12
r W I emify t n I have rend s application un Le that the shove infomudon is
comaelagneer comply with al city and case ordinances and slate laws relating to PERMIT ISSUANCE �� MECHANICAL FEE
F" ,,r, huildingeonsmni ,andberebyinthorlu untativesofthis cirymrnmr upon the
U z above-menrionedpn nyfminspcetion tposes. ALTER OR ADD TO MECH CONSTRUCTIONTAX
(We)agree to so ,indemnify keep harmless the City of Cupertino against
liabilitiea,judgmen¢,co andex ses whichmay in anyway acerucagainst said City AIR HANDLING UNIT('TO 10,0(0CFM)
ton f rhe• rankddou ,�t
/_ AIR HANDLING UNIT(OVER 10,000CFM)
Signature of Applman/Centrac tar Dat EXHAUST HMO(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM.00I BTU)) Date
Will the appBcanr.,far..building m aapnmt stores handle haxufdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and Joe Health and Safety HEATING UNIT(OVER 100,(1!1(1 BTU)
Code,Section 25532(.)'1
CI Yet, ID No VEILATION PAN(SINGLE RESID) r'
Am ili thcapplicantor fmurebuildingmcupant uxcquipmem.rdnittswhich emit
BOILER-COMP(3HP OR 1100,00(l BTU) ISSUA DATE
haza:un air connotations as defined by,he Bay Arca Air Quality Management BOILER-COMP(OVER IW."BTU)
JI""?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,PT.
I have read the has udous materials requirements under Chapter 6.95 of the PAID
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand Mat
if the building does not currently have a wnam,Hat it is my responsibility to notify the JAIL
ccupanr of the requirements which must be mer prior to issuance of a Certificate of JAN 7On�
Occupancy. IJs7
Owoermauth.nu ,.t V�I I 1 N
Dote ISSUED BY:
OFFICE