26011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBu¢mNc-rLRCTRTCA PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT 1'JAMMING-MECHANICAL 26011
///�� IIUILDINGPROJECTIDENTIFICAI'ION
BUILDING ORES'ti� ,^UNITM LOT SANITARY NO. �L�'ON SUBMITTAL DATE
PHONE: ly xLJ ACIOk'SNAMH: - LIC NO: S-41
N/C -CONTROL#
ARCHITEC iENGINEER: LICNO: A313 F-5S. x•-o_ Cu J-tve al, ,r Y ❑
Lot
CONTACT: PHONE: ..
QTY.' FEE
BUILDING PERMIT INFO
' � ,,�:,,�,L•`LCCT'RIC PE
BLDG LIEQJ,' PLUMB ULCHr
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RES L Lam'
cmz I hereby affinni l am licensed underprovisions of Chspw9(commencing with JOB DESCRIpT10N
400 Section 70!10)of Division 3 of the Business and Professions Cade,and my license is in PANELS
W full force and If -
y6U� License lu.s Lie.# f� r 201 02WAMS ��y s
l-��y Dme S Cnmrunnr
'Z8e �' ANCIIITiiCT'S DECLARATION O R PS a SQ.FT.FLO AREA S/SQ.FT.
ONQ lundcrsumA my plans shall be used us puM1lic recotJs. S EL ICAI: O
u
hicenseJ PndexainnalNALED
OWNER-RUILDEIt DECLARATION SP }CIRCUIT N
ex. hereby nflimt thm 1 em ucmpt from the Comractar's License law for the - n n . tt
YJ'SLLN following rcasoa(Seeimn 703 r.5,Business and Professions Cotle:Any city ort0 my TEMP. ROR INST I1V1 ,`./Y
F-E]�; which mquim n Ectasis m conswn,alter,improve,demolish,or repair any ewetum II
syn.)}2 priorwits issuunce,ulsorequirextleaWlicaut forsuch permit to file a signed statement POWER DEVICES
W C C O that he is licensed pursuant to the govivnns of the Cimmancrors Liceme Lew(Chapter -
a-0..o ' 9(commencing with Section 70D0)of Division 3 of Ne Business end Professions Code) SWIMMING POOL ELECTRIC
W_w orthin heisexempt therefrom and the basis for the alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURES 6"z �
2.Z not. 703.5 bya hundred
$500).twbjam N<epplirmnoa civil peneltY of L�•O
wC,i�i not morethanfive}oohed Jollurs(yemp.
wC� ❑ I,uownemDhepmperty.ormyempinyenwith wages aztbeirwlecompemetion, NEW RPSIDGNTIAL ELECIR _SQ.Ff. STORIES TYPE CONSTRUCTION
y3— will do the work,and theswcture is not imendcdaroffercd forame(Set.7614,Business
and t'rofessinm Code:The Contemner;License law docs not apply to to owner of
property whobuikhmimpmvee therena,andwhadocsauch workhimselfor through his OCC.GROUP RES.UNITS
ownemployem,provided Nat suchimpmvcmentsarenotintendedoro(feted fortune.IL
however,the buildingor improvement is mid withinone yearofcompletion,the owner. 0
builder will have the burden of proving that he did not build or improve far purpose of ,
sale.).
❑ 1,mownerofthegop ay,umexclusivelyconvnctingwithlicensedconvnetanto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contra rs
License Lawdoes not apply to anowneroffroperry whobuildscrimprovestherton,and PERMIT ISSUANCE
whocotnmes for such projects with ecomractm(e)licensed pursuamtothe Contractors
License Law. pLfTR-DRAIN&VENT-WATER(E )
FEE SUMMARY
❑ I mm exempt under Sac. ,B&P C for this rcuaon BACK FLOW PROTECT.DEVICE. O ISI
SANITARY Y N
Owner - Data RECEIPT#
DRAINS-FLOOR.ROOT;AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCIIOOL'1'AX. Y
r❑ Thereby affirm that lhave attnificme ofconsem to self-insure,ora certifimte ofRECEIVI'q
Wnrken'CnmMnsmiun lnmmnce oracmifiW copy thereof(Sm.3g00,Lab CJ which PIXTURPS-PER TRAP PARK Ig3fi ,.YN
raven.11 emplayce's undenhis permit. GAS-IA.SYSTEM-I INC.4 01f1'LETS RECEIPT#
Policy# BUII DING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHF.CK FEM
❑ CeniOed copy is hereby famished.
❑ CmifiW copy ie fled with the city inspecfion division. GREASRnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CHRTIFICATR OP B- RMPDON PROM WORKERS' GREASE TRAP SOU-S Mr.
COMPENSATION INSURANCE
(This section need not becompleted lithe permit is for One hundrcddollms(SIM) SEWER.SANITARY-STORM EA.200FT. ENERGY FEE /xa
or less.)
I certify that in the perfarmanee of the work for which this permit is issued,l shall WATER BEATER W/VI!NT/ELECTR
not employ any prosect in any manner so as in become subject to the Workers' PAID
z Cont'nsi mai aweof Cnlifamie. Dam IR
WATER SYSTEM/ EATING Dam Reca
Applicata
ZQ NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t•-I V) become subject to the Workers Compensation provisions of the Labor Code,you must -
l� > forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDI NO FEE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FIiE
rG� I hereby union that hem is a construction lending agency for the performance of
L) O the work far which this permit is issued(Sec.3(197,Civ.C.) TOTAL: ELECTRIC THE
�.y 1<nderx Name
Isndcrs Address QTY. MECHANICAL PERMIT PEE PLUMBING PEE f
LUkI . 1 certify that 1 have rad this application and state that the above information is MECHANICAL FEC
>i coroner.lagreemromply with ell city anJ county ordinanocsend state laws relatingm PERMITISSUANCHVb
M1uildingcnnmranion,enJ hereby wthoriu repmsentasives of Niscitymemer uqm the ,.x CONSTRUCTION9'AX
U mcA.-i edged property,far inspection Purposes. ALTER OR ADD TO MECH. -v ��
(We)agree m save,indemnify and keep harriers the City of Cupertino against
li 'Idies,judgmem. shired expenses which mayin my waysecme against said City AIR HANDLING ON"(TO 10,000 CFM)
i c scqumc the ting !this permit.
-kyr AIR HANDLING UNIT(OVER 10,000 CFM)
d�.D`4 a 1 �I5`{�
Signem 1'Applic .ontmcmr Darr— EXHAUST HOOD(W/DUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE II EATING UNIT(TO 100,000 BM Data Receipt
Will the applicant or future building occupmt store or handle harardous material
as defined by the Cupertino Municipal Cade,Chumer 9.12,and the Health and Safety HEATING UNIT(OVER 100,00121 BTU)
Code,Section 25532(u)7
El Yet ❑No VENTILATION FAN(SINGLE RPSID)
Will theupplicunt or future building occupant useequipmemordevica whichcmit
BOILER-COMP(311P OR IIXI,11M BTU) ISSUANCEDATE
custodians or emnaminnnts as defined by the Bay Area Air Quality Management BOILER=COMP(OVER 13100,000 BTU) PAID-�
>ismici! Y�Yes El No NEW RESIDENTIAL MECH.—SQ.FT. M
1 have rtaJ the motolous materials ou,n emems under Chapter 6.95 of the JAN 0 1994
California I[call,&Safety Code,Section,25505,25533 and 25534. 1 umlerstand that
if the building docs not cmrenrly have a tenant.that it is my responsibility to notify the
oacapam of the rcqulrentems which must be met prior m Issuance of u CenTficate of GhY cur
(kntpmcy.. VUrI11Vu
Owner cur authorised agent Date ISSUED BY:
OFFICE