26774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECT RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 6 7 7 4
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: / // SANITARY NO. APPLICATIONSUBMITTALDATE
N fLi- s UNIT# LOT#
OW ERSN ME: 'x �� AC R'SyAM (/(LIII NO: N/C 7H q-t"64
LIC NO: CONTROL#
RCH /ENGIN R: .GCT .
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. LECIRIPP.RMIT FEE
LDC E .EP PLUMB MECH
PERMIT ISSUANCE / 11 ElLICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
paZ Thereby affirm Netlam licensedunduprovisionsofCTepter9(commencing whh
FW OO bull fen7W0)of Division3of the Business and Pero-afessions Code,and my license is in PANELS
Hu License
a Ialand effect. /� / UPT02MAMPS �M, \ •' � "`�
6 License Class Lic.# / f
va y Dane Contractor 201-1000 AMPS
ZOyZ�. CHITECTS DECLARATION OVER It100AMP5 SQ.FT.FLOOR AREA I;/SQ.FT.
oz-0 1 understand my Firms shall be used as public recoa.s.
gr4Licensed Professional SIGNS ELECTRICAL
g Q OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/M1SC.
�OyF 1 hereby affirm that I am exempt from the Contractees License Law for the
W 3 O so following reason.(Section 7031.5,Business and Professions Cade:Any city orc...1, TEMP.METER OR POLE INST.
�C ol which requires a Fcrmit to construe,alter,improve,demolish,or repair any structure�rn'Y prior to its Asu.nes,alimoouires the applicant for such pumiuo file.signedomement POWER DEVICES
p,O that he is licensed pursuant t°the provisions of the Contractor's License Law(Chapter
9(coonvareng with Seen...9000),f Division 3o fine Business and Pod essians Code) SWIMMING POOL ELECTRIC VALUATION
WM,, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F >'
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of OUTLETS-SWITCHES-FIXTURES 1
� A
out more than five hundred dollars($50y. NEW RESIDENTIAL F,LECB 5 `
ElI,asowneroftheproperty,ormyemployuswithwagesmtheirsolecompemation, Q.F. STORIES TYPE CONSTRUCTION
ywill do the work,and the structure is not intended or offered for sale(Sec.]044,B u0ness
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his
wnemployces,providedthat such improvements art not imendedoroffered forsale.If, OCC.GROUP RES.UNITS
however,the buildingorimprivement is sold withlnone yearofcmmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,asownerofthepropeny,amexclusively, contracting with licensalvar actors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
conswat the pobr,t(Sec 7044,Business and Professions Code:)The Contractors
License Law does rotapplymaanwnerofampeny whobuild.mimprovestherean,end PERMIT ISSUANCE
who contracts for such projects with acormactor(s)licensed pursunntmthe Canneries HESUMMARY
License Law. ALTER-DRAIN&VENT ATER(EA)
❑ I am exempt under Sec. ,B&P C for this remon BACK FLOW PRO .DEVICE FE
OUTSIDE E
SANITARY Y N
Owner Date DRAINS OR,ROOF.ARBA,COND. RECEIPT#-
WORKMANCOMPENSATIONDECLARATION SCHOOLTAX Y N
❑ Thereby affirm thmlheve acertifce[e of consrntto self-intim,or a certificate of _ RECEIPT#
Workers'Compensation Insurance or a certified copy thavof(Sce.3500,Lab C.)which I M RES-PER TRAP PARK HE Y—N
—
covers all employees under this permit. GAS-EA.SYSTEM-1 8T5 RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTB - 4(EA) PLANCHPAK PEE
❑ Cimbied copy is hereby furnished.
❑ Cenified copy is filed with the city inspection division, GREASE TRL WASTE OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' IV.EASET SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundred dollars(8100) SE Eft-SA ITARY-. RM .21ART. ENERGY FEE
or lase.)
I certify that in the e.f k work for which this permit is'mued,lidedl WA HEATER WNEN'1' ECTR
not employ any pri�smr soca r so o h esu aCn the Workers' PAID
7-. Compensation La , .1' WATERS M/f TING Data Receipt#
O Applicant -
0NOTICET PPLI ANT: mrmakingthis ertificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT.
TOTAL'
� become subject to the Worker's Compensation pr isioas of the Labor Cade,you must
�i , ......with-amply with such Provisions.rthis Feint shell be deemed rev°ked. BUILDING FEE
a �]
CONSTRUCTION LENDING AGENCY SEISMIC HE
Z 1 hereby affirm that there is a construction lending agency for the perfomrnnce of
L) O the work for which this permit is issued(Sec.3097,Ci,C.) TOTAL: ELECTRIC FEE
Lender's Name PLUMBING FEE
O F Lender's Address QTY, MECHANICAL PERMIT FEE
L) I certify than 1 have read this application and state tbar the above Information is
�^ W correct.Iegreemc.mplywithallcityand coon rdinances and state laws relating to PERMITISSUANCE MECHANICAL FEE
building construction,andhe authorize ___ so fthiscitymemeruponthe CONSTRUCTION TAX
1..) "� above-memi.ned properly ctio ALTER OR ADD TO MECH.
w+ (We7 agree m sav adernsdy rep a ass ity° no against
liabilities, ems H ay' we mat said Cit AIR HANDLING UNIT(TO ho,oUO CFM)
ener. in ex the
ANDLING UNIT(OVER 10,000 CFM)
Signature of Appli VComrucror Date HAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant mores handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)f
1:1 Yea 13 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the a licannorfuwrebuildin occu an[usee.i BOILER-COMP(3HP OR 100,00(1 BTU) ,
pp g p q purer Quality
Management JUL
Instinctual air contaminants as defined by the Bey Aree Air Quality Management BOILER-COMP(OVER 100,(100 BTU) 19 1994
�Disvie: � V
11 Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the CIT`!Ur uurcM I INU
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior an issuance.f a Certificate of
Occupancy.
Owner or amhmacd.gent Date TOTAL: ISSUED BY:
OFFICE