26196 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB L IN - Lh,DUCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26196
BUILDING PROJECT IDENTIFICATION
BUILDING ADORE ////// SANITARY NO. APPLICATION SUBMITTAL DATE
%�`FUNITM LOTMrff6
OWNER �IkO C 'S NAME: LI
N/C CONTROL
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: ❑
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE % ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCR
p qz Thereby affirmthat lam licensed untlaprovisions ofChapmr9(commencing with - /� �e"tAc
pi100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in ppNELS J�(/b
full force and effect.
GG W License Class Lic.N UP TO 200 AMPS
,o q Date Contractor 201-1000 AMPS — J
F v ARCHITECTS DECLARATION SQ.FT.FLOOR REA $/SQ.IT.
Z,O.� OVER 1000 AMPS
1 understand my plans shall be CT DECLARATION
records.
r4�� SIGNS ELECTRICAL /
W....11 ion
Licensed Professal ® _
Q ding
DECLARATION SPECIAL CIRCUIT/MISC.
U 1 hereby affirm at I am exempt from the Contractor's License Law for the
0
3y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. s�.�
Elee� which requires a permit to construct,alter,improve,demolish,or repair any someone
`" BLI,J
Y� prior m its issuance,also mottoes the applicant forsuch Permit file a signed statement POWER DEVICES
y)
<C) that he is licensed pursuant o the Provisions ofthe Contractor's License Law(Chapter
q eF,4 9(cmmmenelmgwlm Section'!000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC DAT' ON I
my orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWTTCHES-FIXTURES 1
FZQ Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
'yp not inure than five hundred dollars($500). NEW RESIDENTIAL ELEGTR —SQ.FT.
m ❑ Lasawaerofflepmperty,ormyemployeeswith wegeenstheirsolecompensation, STORIES TYPE CONSTRUCTION
q will do the work,and the structom isnotimendedoroffered for sale(Sec.]044,Business
and Professions Code:The Contractors License Use does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his
ownOCC.GROUP RES.UNITS
ear,the building
sack improvements au ntyearef dmpletio d fmmle If,
however,the building orimprovement is sold within one year of improve for theownm-
builder will have the burden of that he did not build or improve for propose of
TOO AL:
proving _ P P rpm
sato.). TYPLUMBING PERMIT FEE
El 1,as ownerofthe property,am exclusively contracting with licensed commuters QTY-1
.t
rs to FLOOD ZONE APN
conswm the project(Seo.7M4,Business and Professions Code:)The Contactor. PERMIT ISSUANCE
License Lawdues not apply a anownerofproperm who builds orimproves Hereon,and
who cmntratsfmr such projects with aconvactomid licensed pursuanttothe Contractor's se Law.
License
ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
ElI am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE T I ES
SANITARY Y N
Owner Date DRAINS-FLOORBOOPAREAGONDBECHT"#
. . , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby afMm that l have a certificate ofconsentto self-insum,or a certificate of FIXTURES'-PER TRAP RECEIPTN
WorkersCompensation Insurance ora cenified copy thereof(Sm.3800,Lab C.)which PARK FEE Y N
rs ell employee's under Hie permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS IEE
COMPENSATION INSURANCE
(This section need not be completed tribe permit is formic hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
mles")
I certify that in the performance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/FLECTR
of employ any person in any manner so as m become subject to the Workers' PAID
Compensation Lawsof California. Date WATERSYSTEMITREATING Date Receipt#
C Z Applicant -
0 NOTICETO APPLICANT:If,eftermakingNis Ceniftcateof Exemption,you should NEW RESIDENTIAL PLMEL SQ.ET. TOTAL
:
4y become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
a [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that there is a construction lending agency for the performance of
O He work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
C ULenders Name
Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
U 1 cenify Hat 1 have read this application and state thin the above information is MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby suthorizerepresentatives of this city to enter opening CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADO TO MECH.
F7 (We)agree m save,Indemnify and ka less the City of Cupertino again
liabilities,judgmeme,casts expense ich yin any wayeccrue ageinet said City AIR HANDLING UNIT(TO IB,WU CFM)
in copse o He g of t Aural
AIR HANDLING UNIT(OVER 10,000 CFM)
gnamre of Applic nt/ mcmr De EXHAUST HOOD(W/DUCT) PAID
1 ZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data ReceiplM
Will the app' ant or future building occupant store or handle limitations materiel HEATING UNIT(OVER 100.000 BTU) TOTAL:
a defined by th Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cede,Sermon 25532(e71
❑Yes No
VENTILATION FAN(SINGLE RMID)
❑
ISSUANCE DATE
Will[heapplicanmrfumrebuildingoccupentuseequipmenmmit rdeviceswhich e
BOILER-COMP(HIP OR 100,000 BTU)
hazadous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
ElYes ElNo NEW RESIDENTIAL MECH.- SQ.Fp. �1 py,
1 have mad the haeardous materials requirements under Chapter fi 95 of the 4 1 0
Califa rm Health&Safety Code.Sections 25505,25533 and 25534.1 understand the
p�
l"if the building does not currently have a tenant,that it is my responsibility to notify the
eventual of the requirements which mustthbe met prior to issuance of a Certificate of
Occupancy.
Owner or auorized agent Date TOTAL: ISSUED BY:
OFFICE