26549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO •SAL PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECT[DEN'FIFICATION 26549
BUILDING ADDRESS: /(����� 7
SANITARY NO. APPLICATION SUBMITAI,DATE
10090 8,0�1 1. xk A-/�+ UNIT# LOT _pp q
O NF.RS NAME: PHONE: CONTRACfOR'SNAME: LIC NO:
NIC CONTROL#
Y �t O
•ARCHITF.CT/ENGINMK: LIC NO: ADDRESS:
054 S. G6-4n?ti (3I0xaLe ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
t0 a 2 I hereby affirm Ihut Imre licen.dvndmpmviainne of Chaprer9(commencingwith
1400 Section 7000)of Division 3.f the 8momas and Professions Cale,and my Ilan.is in PANELS
FZfull fullto. aeffect.
6Class-Lic.# UP TO 2W AMPS
cI-s.<Q Data Can.., 201-IOW AMPS
ZOyZ ARCHITECTS DECLARATION OVER IDWAMPS SQ.FT.FLOOR AREA MQ.FT.
pppp I understand my plans shall be used u public records. #�
°c4 w SIGNS ELECTRICAL
0.fig Licensed Professional ^t 71�
OWI ma exempt
from
the Cc ATION SPECIAL CIItCT1IT/MISC. \ /
x 4 V 1 hereby afOmr @m I um exempt Orem the Contractors License law for the
Hoto following reason.(Section 7031.5.Business and Padeasions Code:My city or county TEMP.METER OR POLE INST, t nn
sn which requires a permit to construct,alter,improve,demolish,or repair any structure s
adY� primm irs issuance,ma.requires their licant for such permitto file a signed mo ment POWER DEVICES \
a G 0 that he is licensed pursuant m the provisions of the Contractors License law(Chapter SWIMMING POOL ELECITUC
ta.am�e 9(commencing with Section 7000)of Division 3 of Ne Business and Professions Cale) u N
yKj_m or that he is exempt herefrom and the but&in the alleged exemption.My Outman of DVILEI'S-SWITCNPSFI%'NRES y e�
QSection 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of - \ 1e
not more than five hundred dollars(SSW). NEW RESIDENTIAL ELECIRS .FT.
m ❑ Lasownemfthe properry,ormyemployeestath wages as lheirsolewmpenautom, Q STORIBS TYPECONSTRUMIO
will do the work,and the structure is not imendedoroffered for sale(Sec.7044,Business
and Professions Cale:The Contractor's License Law doer.nor apply to en owner of
property whobuildsorimproscamereon,andwhodeessuchwork himselfathough his OCC.GROUP
RES.UNITS
own employees,provided that such improvements a.not in tended m offered fortune.If,
however,the building or improvement is sold within one yearofcompletion,theawner- TOTAL:
builder will have the burden of proving that he did not build or improve for purposeof
e.).
❑ I.uowneroftbepmperty,oln sclusivelycornractingwithlicensWcornmcwmto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the projeet(Sec.71)44,Business and Professions Code:)The Commatm'e PERMIT ISSUANCE
License Law does not apply to an ownerof property who builds or improves thereon,and
whocfmmhpursuant cts for such projects with acon .cteds)licensed pursuanothe Condactar's ALTER-DRAIN&VENT-WATER(G)
Limrse Law. FEE SUMMARY
❑ 1 ren exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y_N
Owner Date RECEIPT X
DRAWS-FLOOR,ROOF,AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ers'Co affirmthmlhave aart.Bwte o(conumurafSee.38 .LmC.)nmof X'111RFS PER•LMP RF.CEIPI'#
Wnrken%Campenudion Insurance oraanifiedcopy thereof(See.3g00,LabQ)which PARK FEE YN
coven all employee's under this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cmified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. OREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPRON FROM WORKERS' GREASE TMP SOILS ME
COMPENSATION INSURANCE
(TMs sectionneed net be completed ifthe permit is tutu..hundred dollars(SIW) SEWER-SANITARY-STORM EA.2WFT, ENERGY FEE
a less.)
I cenify rhes in the perhmfance of the work far which this permit is issued,Ish.11 WATER HEATER W/VENT/ELECR
not employ any poen in any mender so as to become subject to the Workers' PAID
Compensmitm Lawsaf C.lifrmi.. Data WATER SYSTEW17REATING Data Receipt
O Z Applicant
z O NOTICE TO APPLICANT:If,eller making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
!-N .lto subject the Worker's Compensation provisions of the Labor Cade,you must
-,
FFFa'" , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEB
Vz I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this Permit is issued(Sec.3097,Civ.C.)
12w 1-•t Lcraft, eName
t" Lender's Address QTY. MECHANICAL.PERMIT FEE PLUMBING FEE
V I certify that 1 have read this application and state that the above information is
kla correct. l agree to comply with all city ural worry ordinances and store laws reading to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby outhodn representatives ofthis city doenterupon the CONSTRUCTION TAX
V Z above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
lamilinesjud efts costaandex swNchmeyineny way aameagainat said City AIRHANDLING UNTT(9'0 I0j"CFM)
con of 'ceratin ofaa
(� /y AIR HANDLING UNIT(OVER 10.Wk CFM)
S' mumof AppicmI/ n tar r Care EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,0W BTU) Date Receipt
Will the applicant or future building occupant store or handle hazardous material' HEATING UNIT(OVER 100,000 ETU)
as defined by the Cuperino Municipal Cade,Chapter 9.12,and the Health and Safety
03C-7
Code.Section 25532(.)7 VENTILATION PAN(SINGLE MID)
❑Yes ❑No
Will theepplicantorfumrcbuildingaaupmt use equipmenmrdevicuwhichemit
BOILER-COMP(3HPOR IW,DW BTU) ISSUANCE ATE
hamnlous air contaminants as dcfned by the Bey Arca Air Quality MaOgQeMenl•
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have read the Wardens materials requirements under Chapter 6.95 of the SEP �#s
California Health&Safety Code,Sections 25505.25533 and 25534. I understand Nm a,
if the building does net
acceptor of he requireracras which
vemaust Ix,lmet
trepriit oris mmyiIssuancereusapnocnesiobfil.ity Cannifotaifym thof
CI Y LO y.
Owner or.uthoriud �r t
N!T t
agent Date TOTAL: ISSUED BY:. V
OFFICE