26893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BllIL.1oni EI.RCTR PERMIT NO.
PING PRNO.MFWENT IFICA 2 6 8 9 3
eun.mrvc DrvlsloN APPLICATION/PERMIT L o 3
BUILDING IsRO.IKC'1'IIIEN'1'IFICA'fION
BUILOINGADDRFSS: SANITARY NO. APPLICATIONSUBMfITALDATE
UNIT LOT.
PHIDNiff. S/0�. CONTRACTORS NAME:- LIC NO: NIC ONTR
AP9A Aiems2s,L6
GINF.Ii LIC NO: ADD Rf.55 ❑
iS1.2
ONTACT: PHONE: wjELECHUC PERMIT FI?E BUILDING PERMIT INFO
BLDG ELECT PLU B MUCH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC IPT
ae'z Iherebyafftnmhat lam licenxdunderprovisiomofChapler9(commencing with '
POO Section 7")of Division 3 of the Buslnessand Pmfnslons Code,and my[I..is in PANELS
full force and c else
F yU al Littn.Class Lic.N JVIi31_1 UPT0200AMPS
may Data Commctor 201-IMAMPS
ZOy/^' ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.ET.FLOOR AREA $/SQ.FT.
O Z�O I understand my plans shall be used ss public records.
E:.m Ew SIGNS ELECTRICAL
<y Licensed Professional
L'W< OWNER-BUILDER DECLARATION SPECIAL CIRCUT/MISC,
N lial
ts.U 1 herchy affirm that 1 arra exempt from the Commcun.Lt..,Low fm the
a oq following reason tio
(Seen]031.5,Business and Probationers Code:Any city or county TEMP.METER OR POLE INST.
,SC)
S�,� which requires.Isenan oconssuct,alwr.improvgdanolAh,or repaifanys outme
m}� primmitsissuanor,nim requires Neupplicant mrvuch permit to file asignamaement POWER DEVICES
Wy A Oz that he is licensed pursuant to the provisions of the Contmemra License Law(Chapter
LXOLL 9(commencing with Section TlX n of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
y) a
in that
a. }a mrom and the e ctte ed e.pmptMypnan of
Sectio7031.5by im,a,, cam fpannitsubjenstbaepnutoacivil penalty of
OTETS-SWITCHES-FIXTURES
notmoehanfivehundred
dflEs($500).
piPeptic c
❑ Lassianpntery,ormyemployeeswithw.gnasei( compensation, NEW RRSIDENTIALELECIA _SQ.FT. STORMS T
VPE CONSTRUCTION
willdo the worlaand the atrucmreis not imendednoffcrtdfor
sale(Sec.]044,Business
vtd Rofnsinns Gale:The Commaors Licenx Law does not apply to an owner of _
properlywyisesi dsmimphat mthereon,andwhoma nen bh workhimselfor through hie
nemployeesilding rimpouucment is within nrniew off opletion,then net,
OCC.GROUP RES.UNITS
however,thehave
building burden of proving that
he did
one build of completion,for
the owner- 'TOTAL:
hull.).(will hove the burden of proving that he diJ not build or improve for purpose of
❑ I,aaownendtbepropcny,em exdwivcly cnmruting withlicensN contmcmrsto QTY. .UMI3INC PF.RMI'F FLOOD ZONE APN
consumer the project(Sec.7014,Business and Professions Cade-)The Contractors
License Law doesnat apply loan ownerofpropeny,who builds or improves thereon,and PERMIT I UANCH _
who contracts forsuch projects wiNacentractor(s)licensed pursuant)the Contractor's ALTF. DRAIN&VENT-WATER TA
License Law. (' ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far Nis reason B K FLOW PROTECT.D'VICD• I FEES
SANE RV Y N
Owner Ume RECEIPTp
WORKMAN COMPENSATION DECLARATION RAINS FLOOR,RCUP,AR ON SCHOOL X V N
❑ I hereby affirm that l have a ceniftcam ofeunxnnn self-insme,ra eeniftcamof RECVIPTp
FIXTURES-PCR RAP
Wmkers'Cmmpen.+Minn Insurance nrecenifed copy @ereaf(Sa.38W,Leh C.)which PARK FEE YN
covenallemp y 'aunder is permit GAS-IA.SYSTEM INC. LET cit"tFTk
Policy M BUILDING DIVISION FEES
Cona❑ CnmifieJ copy is herchy Pomished. GAS-EA,SYSTEM-OV ) PLANCHECK ME
❑ Cenilied copy is file with the city inpation division. GREASEHNDUSTRI. STEI }:RC OR GRADING FEE
CERTIFICATE OF P.XEMPTION FROM WORKERS' GREASIIIHAP SOILS EEE
COMPENSATION INSURANCE
flldsstttion neW nm be completed if the permit Es forone hu whadd.11m,($I00) SHWER-SANIT 'ORM HA Ff. ENERGY FEE
or lass.)
I certify that in the performance of the work for which this permit is ismad,l shall ATER HEATI'.R W/VP.NT . CIR.
not employ any Emam in any manner so as to become subject m the Workers PAID
Comfamusannlawsof Califomia. Data WA SYSTEMITREATING Done RtteiplN
2 Applicant -
hZ 0 NOTICE TO APPLICANT:If,after'making this Certificate of Exemption,you should NEWRESI AL ELME. SQ,Ff. TOTAL:
F' (jp beanos subjec a,Ne Workers Compensation provisions of the labor Code,you must
Grt fnnhwith comply with such provisions or this permit shall he deemed(avoken. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SBISM IC FEE
^a I hereby aff that there is a construction lending agency for Ne per ozrm race of T ELECTRIC FEE
O the work for which this permit is issued(S..3097.Civ,C.)
P Lender's Name
Q
U lander.Address QTY. MECHANICALPERMIT FEE PFE
LUMBING E
L) 1 cenify that I have read this application and state that the above Information is
s�- Lkl correct. I agree to comply with all city ami county ordinances and state laws misting to PERMIT ISSUANCE. MECHANICAL FEE
rF- building construction.and hereby amhmse representatives of this city to enter upon the CONSTRUCTION TAX
U 7 ubovcmcntioned property for inspection purposes. ALTER OR ADD TO MECH.
a
(We)agree to x.ve,indemnify and keep hwMns the City of Culawban St.,,
finbi]Ed dgmems,costs and experoes which may in anyway seem. g.im,m City AIR HANDLING UNIT(TO OAWCI'M)
.11Ionsequen)stare ting aft ii.
AIR HANDLING UNIT(OVER 110.000 CPM)
Signe App m/Cotuma Date EXHAUSTIIOOD(W/DUCn PAID
IIATARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 10,0100 BTU) Date Ra
Will the applicant or town;building mcupant stem or handle hazardous material I IFATING UNIT(OVER1010,000 BTU) AL:
.s defined by the Cupertiw Municipal Cale,Chnpta 9.12,end the Heehh anJ Salbty
Cade,Section 25532(.)7 VENTILATION RAN(SINGLE RESI))
st-
11 Yes ❑No
14 BOILER COMP(3HP ON 1010,IIOD BTG) ISSUANCE DATE
Will the.pplicantorfuwmbuildingmcupantuxeyuipmeniordeviceswhichcmit
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District,
:1 Yes El No r NEW RESIDENTIAL MECH.-SQ.FT.
1 have mad the haaawk us materials requirements under Chapter 6.95 of the GT'L 1gg
California Health&Safety Code,Sections 25505,25533 and 25534. 1 mtderswnd Nat
if the building does not currently have a tenant,that it is my responsibility to notify Ne
occupant of the.quimnams which.must Fa met net to issuance of a Cmireate of
Occupancy.
Owner or mthodzcd agent Date ISSUED BY:
OFFICE