26067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIIILDING.1alX•OTRI'AI. PERMIT'NO. /� /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL '/ 6 O C
BUILDING p@OdIS(:I'ID1[N'fIl'IGA'IIGN L V U
1 G DDR S.S. SANITARY NO, APPLICA�TIOONN�SUBBMITTAALL DATE,
UNIT# LO'1'q /�Yl/GK
NL'RS A
VAR CON'U1ACI OR'S NA LIC NO: �V __ ♦♦ 7J)
_ NIC CONTROL#
ARC1R .CT GI E.R: LIC NOi AD E .. ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEfi BUILDING PF,RMIT INFO
BL O ELECT PLUMB MUCH
PERMIT ISSUANCE T4�
LICENSF.DCOMRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DDEESCRIPI'ION
py.Z Ih7")ofi Division
can 3 ofthnsad undernd Professions
Carr and mmaou,cense with 1w�`"Vv�
WOO full forefandofect. on3of the Business and Professions Code,and mylicenseia in PANELS �a11
FtyUFU fullforceClndeffect. --
FZ W License Class Conte IR T0200AMPS
tau
eras Uate Contract 201IgM)AMPS
Z I ti= ARCHITECTS DECLARATION 10SQ.IT.FLOOR AREA S/SQ.FT.
OVER 00 AMPS
O Z—0 1 understand my plans shell be users as public records.
Z 4ee-W SIGNS ELECTRICAL
<Rd Licensed Professional
d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC,
kO a V 1 hereby affntn that 1 em exempt from the Cortisone,License Lew(or the
W 3O to following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
f"E m J which requires a permit to construct,rarer,improve,demolish,or repair any suvesure
W;!(};� prior to its issuance,alsore ires the applicant for such Permit o file asignMsmement POWER DEVICES
sG OK that he is licensed pursuant m the provisions of the Commmu es License Law(Chapter
S
keLL 9(commencing with Section 1000)of Division 3 of the Business end Pmfessioru Cade) SWIMMING POOL ELECTRIC VALUATION
W•_,,, or that he is exempt merefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �\
Z Q Section 7031.5 by any applicant for a ps mm subjects m the applicant a civil penalty of
not mom than five hundred dollars($500). NEW RESIDP.NI'IAL EGIR _SQ.Ff.
Sl'O 5 TYPECONSTRUCI'ION
n. m ❑ othe w work,
is not
or thwed forsale(Sm.compensedan,
d will da the wons end the he Contra mot intende se Lawoffe
s not apply t oan owner
of
ss
and professions Cade:The Ces flue ar Liana i Law dos not apply torn owner of
progeny who 6,1175 or improves therea4 end who dassacM1 work hi mse l f m through his
employtta,pravidedthatauchimprovemenu erenotimrntledaofferedTarsale.If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year of cwnpletion,the owner
builder will have the burden of proving that he did not build ar improve for purpou of
sale).
❑ I,aeownerofthepmWny.emexclusivdycont ingwiNlicens wfltmctonm PLUM UNG PERMIT FEE FLOODZONE APN
construct the project(Sec.1014,Business and Profusion Cale.)The Coo—oa's
License Law does not applyman owners(property who buildsmimproveamuenn,end PERMIT ISSUANCEmesississ
who contacts fm s uc h projects wi th s comae tots)I icenud pursuant to ted Catm actors
License Law. ALTER.DRAIN&VENT-WATER(IA7 FEF.SUMMARY
❑ I am ucmpt under Sec. ,B&P C fm this mason BACK FLOW PROTECT.DEVICE OUTSIDEFEFS
SANITARY Y N
Owner Date DRAINSFl,OON,ROOF,AREA.COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsentto self-insum,me anificam of FlRFCF.IPT#
XTURfS PER TRAP
Wohers'Compcmation lnsurence orvamified copy thereof(Sec.3800,1ab CJ which PARK FEE V N
save.all employtt9 under this permit. RECEIPT N
GAS-EA.SYSTIiM-I INCA OUTLETS
Policy BUILDING DIVISION ••PS
Company OAS P .SYSTIiMOV1iR4(FA) JENR(GY
CIIECK GEE NG ?3P
❑ C<nifed copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GRfA FJIN ASTtjI F: CE OA. ING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA.StETR I's /I t 1>• FEE
COMPENSATION INSURANCE
(This sommnmednat be completed ifthe permit is foron,hundred dollars(SIM) SEWS -SANITARY-STORM FA.200 NEE.
or less.)
Icenifymat inthe perfomtanceofthe workforwhichthispermit is issued,l shall WAI. H TEDkV
not employ any person in any memtm sa as to become subject to the Workers'
Compensation Lawsof Califomie. Dam WAI'ERSYSI'EM/TREATING Dam Receipt is
0 z Applicant
Z P NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should NEW RESIDENTIAL FINE. SQ.ff. TOTAL:
(In became subject in the Worker's Compensation provisions o(the labor Code,you must
forthwith comply with such provisions or this permit shall be deemed smoked. BUILDING PEE
SEISMIC FEE
4 Q
CONSTRUCTION is ac ION LENDING AGENCY
z 1 hereby nicht that there is a coat(Sec
lending agency for the Performance of
V O the work far which this permit is issued(Sec.7097,Civ.C.) T 'AL: ELECTRIC NTE
Leadels Name
U" Lindera Address QTY, MECHANICALPERMIT FEE PLUMBING
kkI 1 certify that 1 have read this application and sum that the above iarmor ation is MECHANICAL P E
correct.I agree to comply with all city and county ordinances end sure laws rctatingm PERMIT ISSUANCE
building construction,and hereby authorize representatives nam dry to crier upon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purpose. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless me City of Corcoran against
juJgmen ,mersande whi may in any way acri e,iinat said City AIR HANDLING UNIT(TO 111,0(#]CFM)
ceof egmntin i pe t AIR HANDLING UNTT(OVER I0,009 CFM)
Signtu of Applicant) ort cin Da¢ EXHAUS IT 1OOD(W/DUC1') PAID
HAZARDOUS MATERIALS DISCLOSURE I IEATING UNIT(TO IW,000 BTU) Date Receiptq
W ill the applicant or future building occupant store or handle hazardous amandi l HEATING UNIT(OVER 1(111,0(10 B'I'll) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)1 VENTILATION FAN(SINGLE RESID) t
❑Yea ❑No
ISSUANCE DATE
Will he applicant orfuwrebuilJingwcupanmseeyuipmemor devices whichemit
TOILER-COMP(31111 OR IWRM BI U)
hazardous air cnnmminunta as defined by the Bay Area Air Quality Management BOILER COMP(OVER TOO IXXI RTU)
Di ries, Y
❑Yet as
NEW RESIDENTIALMECIL SQ.IT.
1 have read the hazardous materials requirements under Chapter 6.95 of the ���
Californiaath Health&Snfasy Cole,Sections 255(15,25537 and 25534. 1 understuntl that n A�
I
the huilAing does nm currcmly hove a tenant,then it ie my responsibility In roily the (�
occupant ol'thc requirements which nmst be met prior m Issuance of u Certificate of /s
Occupancy. oil)- 6
Owner or authorized agent Date TOTAL: ISSUED BY�
OFFICE