26233 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUR.6ING ELF,CTRICA. PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING MECHANICAL n Q 2 3 Q
BUILDING PROJECT IDFIFICAI]ON
LV JJ
B I,DING ADDRESS: ����(( SANITARY NO. APPLICATION SUBMITTAL DATE
lo'] 3S MA2T1Nlnioa40 WGFIT LOT ���
NIiRSON�M 0� ��PHONE: C X14. S 916n/O4/ LIC NO: 111
'' 11 LL ,A E N/C CONTROL#
•ARCIII'I'ECI'/IiNGINEER: LIC NO: ADDRESS: 64 / C
CONTACT: PHONE: QTY. t� ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PI,.UMB MF,CH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyy Iherebyaffirtn Nm tarn licensed under provisionsofCTapter9(commencing with LOB DESCRIPf N
w00 Section 0000)of Division 3 ofthe Business and Professions Code.and my license is in PANELS
o: F. as
FZWf.,ccmccand-(tect.
Liccntt Class Lic.p UP T0200 AMPS 1./�a :=)
w4a D:nc Contractor 201-1000 AMPS
Z Ov°'sz ARCIIU'ECTS DECLARATION SQ.FF.FLOOR AREA $/SQ.IT.
I understand my plans shall Is,used as public records. OVER ELL AMPS
INALED IN
^F to 7 w SIGNS ELECTRICAL
?pW< Professional
l4ussional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. nI,/nJ `�` fp.��
XOwu I hereby affirm that 1 om exempt from the Conuactors License Law for the ® Y V Y p U u �� II a
w3 wy following....(Section 7031.5.Business and Professions Codc:Any city.,county TEMP.METER OR POLE INST.
f'�L O a which requires a permit to construct,alter,improve,demolish,or repair any immune D
C�aS prior to its issuance,also requires the applicant for such permit fileesignN statement POWER DEVICES ATE
w C<O that he is licensed pursuant to the prosmars.f,he Com actoe,License Law(Chapmr SWIMMING POOL ELECTRIC
d4oLL 9(commencing with Section Z000)of Division 3.f the Business and ProfcAmas Code) - VALUATION
Amy of that he is exempt therefrom and the basis for alleged exemption.Any violation of
rya Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCf1E5-FIXTURES
not more than five hundred dollars($500).C NEW RESIDENTIAL ELECTR S .1'r.❑ I,asuwnerofthe propcny,ormyempinyas with wagesasthcirsolec.mpensalion. Q S'T'ORIES TYPE CONSTRUCTION
pw,3_ will do the work,and the structure isnot intended.,offered for side(See7014,Business
and Pmfessione Code:The Cmimmu is Liecnse Law does not apply m an owner of
property w ho ba ilds m improves dims,and who does such work hlmsel f m through his
cmploYees,providedthat such improvememre
sanolinendsJoroffered fmaele.If, OCC.GROUP RFS.UNITS
however,the building orimprovemem is sold within one yraroemopletion,theowner- TOTAL:
builder wil I have the burden of proving that he did not build or improve for purpose of
salt')' QTY. PLUMBING PERMIT FEE
❑ I,asownerofthe proany.umendusivdyanaacting withlianseJ conwaonm I1.00D LONE APN
construct the project(Sec.7014,Business and Professions Code)The Contractors
License Law does not apply to avooner of property who builds or improves thereon,and PERMIT ISSUANCE
w1 lose,fu,oteb projects with a co.,.emr(s)licensed pursuant to the Contractors
Licensee Lsw. ALTER-DRAIN&VENT-WATER(PA) FEC SUMMARY
❑ I am enempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-Fl.pOH,ROOFARFA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX Y N
❑ Iberebyaffirmthatlhaveacenificamofeonsenuo self-insure.m.arificamof FIXTURES-PER TRAP RECEIPT#
Workers Compensation Insurance m acenified copy thersoffSm.3800,Lab C.)which PARK FEE Y N
n all ereIo ce's under this permit RECEIPT#
P Y GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FE
vol�y x
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Certified copy is hereby furnished.
❑ Crefted copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICAT17 OF EXEMPTION FROM WORKERSGREASETRAP SOILS PEE
COMPENSATION INSURANCE
O3tissati.sad notbe completed iNIm .it is function hundred dollen($100) SEWER-SANITARY-STORM EA.20OFf. ENERGY FEE
or less.)
I certify that is she performance ofthe..A for which this permit is ismed,I shall WATER HEATER W/Vfif LECTR
not employ any person in any tvrvrcr so ar to become,subject to the Worker' PAID
Compermtionlawsof Califomia. Dam WATER SYMNUTREATING Date Receipt
zZ Applicant
Q NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should NEW RESIDfiAL PLMB. SQ.FT. TOTAL:
zl
�+ become subtt
jecothe Workers Compensation provisions ofthe Labor Code,you must
toe' 7 fonhwith comply withsuch provisions or this permit shall lx deemed revoked F,
BUILDING FE
a (� CONSTRUCTION LENDING AGENCY SEISMIC 193E
I hereby affirm that them is a construction lending agem
agency for the performance of
U O ( ELECTRIC FIiL
the work for which this permit is issued(Sec.3119'!,Civ.CJ IA A
1I<adc-Nara PLUMBING FEE
0 F Lender's Address QTY. MECHANICAL PERMIT FEE
U I cenify that I have read this application and state that the above information is MECHANICAL.FEE
>_ D.1 correct I agree to comply with all city and county ordinances uM since laws mlNng to PERMIT ISSUANCE
F" CO TuAldingconswcti.n.and hereby auhoria representatives ofthis city memvuprn Ne CONSTRUCTION TAX
U Zi abovrmentimed property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Ii abilities,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT CTO 10,000 CFM)
in m<yucnce of the gramin of thi pemm'.
Cq _C_a AIR HANDLING UNIT(OVER 10.000 CFM)
i / J /
Signature of Al,Picant/Contmcmr ])atm EXHAUSTHOOD(W/DUC , PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt N
Will the applicant or future building occupant store or landle hawdous material HEATING UNIT(OVER 100.01X1 BTU) TOTAL:
u defined by the Cupertino Municipal Calc.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESET)
❑Yes ❑No
ISSUANCE D 'I'E
Will the applicanturfmure bvildingoccupm use equipmentor Jeviceswhich emit BOILER-COMP(311P OR RXI001)BLV) pp
ha',od.u.a air contaminants as defined by the Bay Are.Air Quality ManagementA
BOILER-COMP(OVER HaLkyl BTU)
Idkldol
❑Yes ❑N. NEW RESIDENTIAL MLCH. SQ.111%
I have mud the hazardous materials requirements under Chapter 6.95 of the On 5.
California Health S,Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not curtail,have arenanttha itis my responsibility m /s notify the n//N b •V s7`iI
I h r
cupant of the requirements which must be met prior m issuance of o Certificate oI � /a-
Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE