26429 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HnHR eI.ecTRrcAII PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PL4AL 26429
BUILDINGPROJFCfIDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPI.IC,VnONSUBMDTN,DATE
/i G/ LOT# J(i,,,��
'0 A M ' PHONE: CONT 1n--r G)wAj c04� TIC NO r N/C CCOONTTRROL 4I•
idIRCHITIRCTIENGINEER: LIC NO: ADDRESS ❑
ie� / 30/�Hiu Nn nl
CONTACT: PHONE: BUILDING PERMIT INFO
k QTY. ELECTRIC PERMIT FTE
BLDG ELECT PLUMB MF:CII
PERMIT ISSUANCE ❑ ❑
LICENSE DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ IM17000)of
mvision n that Is.lice Business
itvision.ime,Code and mmenense with
W OOF. Section llore ce and e f Division 3 afthe Business end Professions Code-,and my license is in PANELS
FZW License Class Li<.p UP T02l0 AMPS
to=y Date Cnmracmr 201-1000AMPS
FyZ ARCIfITECTS DECLARATION OVER IOOOAMPS SQ,PI'.FLOOR AREA 8/SQ.II'.
I understand my plans shall be used as public records.
OZ-0
SIGNS ELECTRICAL
G Y�jW LlcenseJ professional
C ttQ OWNER-BUILDER DECLARATION SPECIALCIRCUTUMISC.
5c5d�'O i V 1 hereby affirm that 1 am exempt from the Contractor's License Low for the
u13 ay followittIl.soa(Section 7031.5,Bminess and Professions Code:Any citymcounty TEMP.METER OR POLE INST.
which requires o pelmil to conawm,alaq improve,demolish,ar repair any swcture
>1 prior to its issuance.also requires the applicant for such permit to file a signed statement POWER DEVICES
aW fG pp that he is licensed pursuam to the provisions of the Contractor's License Use(Chapter SWIMMING POOL ELECTRIC- �-
0 9(co:mnencing with Section'ILi1()of Division 3 ofthe Business and Professions Code) I VALUAT 'bC
W=m an1km703eumpttherefmmond the basisfortheallegedeaemant to A ivilpeauon of OUTLETS-SWO'c". (�{•
F�< Section]0315 by tiny aPPlicnm for o permit suhjeas the applicant m a civil penally of
not more than five hundoul dollars($500).
`zL NEW RESIDEMnAL ELECTR _SQ.FI'. S3ORIFS TYPIi CONSTRUCTION
a3p� ❑ I,uownerofthepropery.ormyemploytts wiNwagesazthcirsolecompem¢tion,
will do the work,and the strecwm isnot intended oroffemd foraale(Sec.7W4,Business
and Prolcvsions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves theaon.and who does such work himself or through his
OCC.GROUP NES.UNI IS
wnemployecs,pmvided Nprove impmvld wit in ne yeandedoroffered'heown1f,
however,the
have
Or den of proem issoldbe id not build orimprose for urporer- TOTAL:
builderwill l have the burden of proving that he did not buil)or improve for puryase of
sa10. QTY. PLUMBING PERMIT FEE FLOODZONH APN
❑ I,as owner ofthe property,amesclusively, contracting with licenudeam
nrnorslo
Instruct the project(Sec.](144,Entries,and Professions Cade)Thc Contractor's
License lawdncs not applymanownerofpropcny whobuilJsorimprovu Nerum.and PERMIT ISSUANCE
whocommcts for such projects with acoamacrar(s)licensed pusuanuo the Conlrsdofs
ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
License Law.
❑ 1 um exempt under Sec. ,B&PC for this reasonyACK FLOW PRO'fGCf.DEVICE TSIDE P EES
SANITARY YN
Owner Dale DRAINS-FLOOR,ROOF,ARECOND. RECEIPI'p
A
WORKMAN COMPENSATION DECIARA9'ION SCHOOLTAX YN
❑ thereby dfiiml that l have a certificate ofcomenl to self-insure.or a cenificete ofFI%TURES-PER'IRAP RECHU'r#
Workcri Compenmtion lnauranceoracenifed copy thereof(Stt.3800.IsbCJ which PARK FEE YN
enECFIP
DIVISI
all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RIVISI p
covers# BUILDING DON FRES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCt{EEK HE
❑ Certified copy is hereby famished.
❑ Cenilied copy is fled with theclty inspection division. GZSfJIND T GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIi TRA L� fk`[T IlajWR7P(jR-'. - r, • t SOILS FEE
COMPENSATION INSURANCE ''II
('Hissecfmu need not he completed ifthe Prodi is far one hundreddellit.($100) SEWER-SAN ARY(;STOR[,1�ry2 IPC I J `m J' ENERGY FCC
or less.)
I certify that in the performance of the work for which this Permit is issued,i shell WATER IIFATERW LECIR
not employ any person:n any manner m es to become subject to the Wonkels' PAIDI
Compensatioul.owaof California. Date WATER YSfTREATING _,A Date Receipt#
0 Applicant« NEW RESIDENTIAL PLMB. SQ. r TOTAL:
•� NOTICE TO APPLICANT:IL after making this Cerificric of Exemption,you should
lA bomn
esubjeco the Worker's Comen
psation provisionsafthe Labor Code,you must O861LDING FEE
� > forthwith comply with such provisions or this brut shall h deemed revoked.
1 Q CONSTRUCTION LENDING AGENCY NJZivIC HE
z I herebyaffirtr than here iso construction leadingagency for the perfn..of
ELECTRIC FEE
O the work for which this permit is issued(Sm.3097.Civ.C.) T
lender t None PLUMBING FEE
I, F Lender's Address QTY. MECHANICAL PERMIT FEE
C1 1 certify Cher 1 have read this application and state Nat the above information is MECHANICAL FEE
>" Uj correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
(— building construction.and hereby anthems representatives¢flhis city to enter upon the CONST RUCTION TAX
[, z above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)store in save,indemnify and keep harrtJcss the City of Cupertino against
habiliies,judgments,costs andexpenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
in corse encc f the i of this psonit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si amr al'AppheeseVContjraroor Uma EXHAUST HOOD ONMUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100 BTU) Date Rccciptp
00,0
Will the applicant or l more bei lding occupant stare or handle hmardoes material HEATING UNIT(OVER 100.001)HlU) TOTAL;
ss defined by the Cupertino Municipal Code.Chapter 9.12,emJ the lleahh and Safety
Code,Section 25532(a)T VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
Will Ne applicant or fuwmbuildingwcupanlnseeyuipmemmdeviceswhichemit BOILER-COME LAW OR 100,000 BTU)
�M1azardam air contaminants a,defined by be Bay Area Air Quality Management BOILER-COME(OVER LUEWO BTU) r K 0
Oistnctt
❑Yes ❑No NEW RESIDENTIAL MF.CII. SQ.FT.
I have rand the ItvuMous materials rayuiremcntn ander Chapter 6.95 of the """AY 26 1994
California Health&Safety Code,Sections 25505,25533 and 25534.I understand Ihm
if the building does nm
occupant of the requirement,which
vemust Ire me,apt h oirs to yissuance
siobfiliuty Cerrmniofitiafya thof
n
il y f f�
Occupancy.
Owner or authorived agent Dna TOTAL: ISSUED BY:
OFFIC