26863 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BmrnTNO-ELEETRrCAL FERMI I NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /N/N /N ^ /N
3
BUILIIINLG PROJEC`p IDENTIFICATION Y6 VM 4V•
BUILDINGADDRESS: /,/��/ SANITARY NO. APPLICATION SUBMITTAL DATE
•• IUNIT# LOTp //
OWNERS NAME: PHONE: COyURACfOR'S NAME: LIC NO:
S NIC CUNIKUL#
ARCI'1'F. /ENGINEER: LIC NO: A DRESS: pp,,
CONI' CI': PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
'�/ BLDG i F.LELT /PLUMB/ MECH
PERMIT ISSUANCE LOy IsE PLUMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
DEpSC�RIP�TION
py.Z, Ihereby 110.1' mthml am oflhe sed Business
rofesions Coer and mmmense with �7ZA �l�
�i100 Section nce and of Division lofthe Businua anti Professions Code,end my license is in PANELS JFe
full fore Cla effec � UPT0200AMPS
LoZ,ty I.ittnm Cl Lic.#
rFiay Dare Contmnnr / 201-1000 AMPS
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.ITT.
OZ—C I understand my phour,lill M used us public,mmds.
SIGNS ELECTRICAL
Licensed Professional
�P�WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oa 1 hereby affirm that I sm exempt from the Cmuncims License Law for the
3 0.In fallowing reason.(Section 7031.5.Business and Professions Code Any city or county TEMP.METER OR POLE INST.
C LL Oos which requires a permit to construct,alter,improve,demolish,or repair my structure
CQ� prior to its issuance,also requires the applicant for such permit o rile a signed statement POWER DEVICES
yFYOO thm he is licensed pmusalto the Provisions of the Contractor's License IA.(Chapter
o-p,o 9(commencing with Sminn700f1)of Division3of Ne Businessmd Pmfueiona Code) SWIMMING POOL ELECTRIC �yjr��LUA/TION
yYj,-,y nnhm m
he is exempt therefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
f-, 4 Section 7031.5 by any applicant for o Permit subjects the applicant m a civil penalty of \7 Yx�77
tmmc Nan five hundred dollms($5W).
04 p m❑ I,asownerofthepmpeny,ormyemployeeswithwagesastheirsole compematiNEW RESIDENTIAL EI,ECfR _on, SQ.IT. e, (� \\ STORIES PE CONSTRUCTION
y _ will do the work,and the structure is not intended ormfferedforsale(Sm 70,14,Business / l
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimproves thmeon,and who Joessuch work himsaforthruugh his ro .GROUP RES.UNITS
own employees,provided that such imprnvemcros me not imentled or offered fouale.
If,
however,the building or improvement is sold within one yemofcompletion,theowner- TO
builder will have the burden of proving that he did not build or improve for purpose of .5.
❑ )1,mownerofthepmpcny,amexclusivclycentmctingMthlicensedcommnomto QTY' PLUMBINGPERMIT V1kC FLOODZONE APN
construe,the project(Sec.IDM,Business and Pmfessiom Code:)The Covumtm's
License Law does not apply man owneroforoPenywho builds mimproven Nercon,and PERMIT ISSUANCB �a
who contracts forsuch projects with aconractods)licensed pursuant to the Contracture ALTER-DRAINffi VENT (EA)
License Law. IEC SUMMARY
❑ 1 em exempt under Sec. ,B ffi P C for this rcmon BACK FLOW PROTECT,DEVICE T
SANITARY Y N
OwnerDam DRAINS-FLOOR.ROOP,AREA,GOND. RECEIPfp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ Thereby affirm thatlhaveecenificam of cmnxnuo ulf-insure,urn cenilicare of RECEIPT#
FIXTURES-PER TRAP
Workeri CnmpensationlnsumncearecertiBedcopy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers uliemplay n RFCEIPTp
�j' tlyyfyp GAS-EA.SYSTEM-[INCA GIITLET$
�
Policy#
( wjl�� BUILDING DIVISION FEES
Cnmpsny ��— An �� GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑17-ifcal copy is hereby tumis tial.
Certified copy is filed with the city inspection division. GREASEANDUSTRI,WASIE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
("is section need not beconplued ifthe permit is forone hundred dollars($11101 SEWER-SANITARY-STORM PA.200FE ENERGY FEE
orlem.)
I cenify that in the perfrrmanceofthe work for which this permit is imued,Ishall WATER BEAT'IM WIVENT/ELECTR
not employ any person in my manner so as to become subject to the Workers' PAID
Compensation Lawsaf California. Data WATERSYSTEMfMEATING Dam Receipt#
0 O NOTICEtTO APPLICANT, after making this Ceniftcate of Exemption,z ... Labor
you multi NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F rn become hwithc subjecttowie Workers Compensation prmisiama(eemost invoked.
must
Ki 7 forthwith comply with such provisions or this permit slWl be deemed revoked. BUILDING I'L•E �s
Z
CONSTRUCDON LENDING AGENCY SEISMIC FEE
I hembyaffum unit there is timum-uctihm leading agency for me performmcaof TO ELECTRIC FEE
1, O the work for which this Permit is issued(Sm.3097,Civ.CJ
{1-t (r Lender's Nue t FEE ILL.u PLUMBING FP.P.
[�-h m
Lender's Address QTY. MECIIANICALPLRMIT I�
V 1 certify that I have rend this opplicaion sod state that me shove information is
comm.l agree mcomply with all city and countyoMinmces snit state laws relating m MECHANICAL.FEE
PERMIT ISSUANCE /�
rA buildingetnstruction,andhercby authorize reammuctivesofthis city to enter upon the CONSTRUCPIONTAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless Be City of Cupertino against
liabi s,judgments,cosumdupenses which may inmy way mane against said City AIR HANDLING UNIT(TO IB0pBCFM)
ine m uenaof Negrenringoftbis pe
oe AIR HANDLING UNIT(OVER I O,g10 CFM)
marc of ApplicmUCormaremr am EXHAUST HOOD(WMUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1011,0810 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hurardous material HEATING UNIT(OVER 100,0W BTU) OT
m defined by the Cupertino Municipal Cale,Chapter 9.12,and the Umdth and Safety
Rule.Semi 25532(u)7
0Yes L1 No VENTILATION FAN(SINGLE RISID)
Will theaPPlicmtafuture buildingmccu ant useeuiprmmrdeviwhichemt BOILER-COMP( HP OR[00,000 BTU) ISSUANCE DATE
•
hmnNom sir carnaminants m defined by the Bay Am Ah Quality Management BOILER-COMP(OVER 100,000 BTI) pp pp QQ��
District? Lit GY 7 RY
❑Yes ❑No NEW RPSIDENTIAI.MECH. SQ.FT.
I have read the fmtycm.materials mquiremems under Chapter erst of the AUG 11 199
ifthon o,, aSafety Code,Seninns 25505,25533 and 25534.Iuntlerctanf than
if the M1uiWimg caml curten0y haute ten,that is my rmponsibility mnotify the
nl'the reyuircments which n Ix met pr #a Ce team of s
Om, n GIiY Ur m r .
O or uwhorized agent Dote T ISSUED BY:
OFFICE