26510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 5�I 11 ILD .-ELKCIRICAL PERMNO.
APPLICATION/PERMIT PLUMIfIL IT
NG-MF,CHANICAL O
BUILDING DIVISION BUILDING PROJECTIDENTLFIC-ATION' J 1
BUILDING ADDRESS: SANITARY NO, APPLICATION BMITTALDA'IL
00
UNITN LOTQitiapp
OWNS S EONE: �� C Cf 'S NAME:� LIC NO
JeYIJ N/C CONIROLp
�ARCHI dGT/ENGINEER: LIC NO: ADDRE : ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMITISSUANCE I(TSI(\ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTLIL JOB DESCRIPTIO
CC> lherchyaffrm that l am licensed underprovisionsof CTaptert)mommencingwith
jal00 Secllan]hW)Of Uivision 3nf the Bminess and PndBssions Code.anA my license is in PANELS �y �!'
KUF fullforttanJ cffcct.� �5' q^J ' 0
II6..zW license C,{'�s Liap � / 7J UP TO 200 AMPS
i s:D Date ConTSD 201-1000 AMPS
Fy< ( ARCIIITECI'1 DECLARATION SQ_FTJLOOR AREA SISQ,FT.
GOrn— l understand my plamshall be used as public records. OVER IOOU AMP 1p���
Oz—O Y V
�yFW SIGNS
ELECfR CAL �...
IJcenscA Professional
FyW< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I�
xx0 a. I hereby affirm that 1 am exempt from the Contractor's License Law for the
tt�3Wy IiJbwing rcamn.(Setlion]03 t.5,Buanmss and ProfessionsCMe:Any city orcounty TEMP.METER OR PO INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
C�QM prior to its issuance,also caroms the applicant for such Permit to file a signed statement POWER DEVIC
W�pO that he is licensed pursuant to the provisions of the ComucloCa License Law(Chapter SWIMMING PO&G,
Kea 9mimmcncing with Seonoo 7000)of Division 3cfthe Business and Profnsimm Code) VALUATION
W—y m dao he iseaempr thercfroor it Ne basis for the alleged exemption.Any violation of �(
OUTLETS-SWITCHES-FlXTURES
ZQ Section than by anyapplicant for apemrit subjects the applicant toncivil penalty of 0
nal me rofhundreddollars($SOUL
SSp NEW RESIDfiNT1A1.ELF:CfR _SQ.FT. STORIES TYPE CONS'fRUCI'[ON
6a'F-22 ❑ locwork.ond the spcny.mmyemplayceswiOwed!for lic(S .cumpensiiess
3°0 will duthewons,and the she Contiactorinteicense Law
os of apply 704W.Business
and Pm(casions Civic:The Contractor's License f:rw docs not apply to an owner of
property wbo builds or improves thereon,and wha does such work himself or through his
employces,Provided that mchimprovenent
ls am notimendedoroffned formic.If.
OCG GROUP RES.UNITS
however,the building or improvement is sold withinooe yeaofcampletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,asownerofthepmpeny,amexclusivelycontractingwidr licensed cantnaorsm
construct the'pmject(Sec.7014,Business and Professions CmJc:)The Communist's
License lam does not apply to an ownerofpropeny whobuilds or improvestherenn,and PERMIT ISSUANCE
who contracts forsuch pmjma with a morticians)licensed pursuant oche Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sm ,B&P C for this reason HACK FLOW PROTECT.DEVICE: O SIDE FLITS
SANITARY Y N
Owner Date DRAINS-fLOORROOFARPACOND. RECFIFT4
. , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihumbyaffnn lM1mlM1uveacenifonc of ennaom mxelf-insure.or acerlifcate of FIXTORES-PER TRAPRECEIPTp
Workers'Compensation laaurnnce ora certified copy flamof(Sec.3900.Lab C.)which PARK FEE Y N
rs all employees under this permit. GAS-EATE
.SYSM-I INC.4 OUTLETS RECEIPT'M
Policy n BUILDING DIVISION FEES
Company y q ` GAS.EA.SYSTEM-OVER 4(EA PLANCHECK Fill.:
❑ Cenifedc�y is hcmby famished.
Cenified copy is riled with the city inspection division. GRFASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
/�ICY' CERTIFICATE OF EXEMPTION FROM WORKERS' OREASETRAP SOILS FEE
COMPENSATION INSURANCE
(lhi.s,ectionrood not be compleed tithe permit is formic hundred dollars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or leo.)
I certify that in performance of the work for which this permit is issued,I mall WATER HEATER W/VFNT/ELECTR
not employ any person in any manner so as to become subject to the WOrmax PAID
zCompensation Lawsof Culifamm. Dam WATER SYSTEMRRFATING Date Receipt#
Applicant
NOTICE
NOTITO APPLICANT.If,after cocking this Certificate of Enemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
u ismonte subject o the Workers Compensation provisions or the Labor Code,you most
foMwith comply with such provisions or this permit shall be deemW revoked. BUILDING FEE '.-,-
[llSEISMIC FEE
Q CONSTRUCf1ON LENDING AGENCY
z I hereby affirm that there is a construction lending agency for the performance of 'TOTAL: ELECTRIC FEE
U O the work for which this pnmit is issued(Sec.3010.Civ.C.)
lendn's Name PLUMBING FEE
U" Lender's Address QTY. MECHANICAL PI7RMIT FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE
correct. l agrte to comply with all city and county ordinances and nam laws miming to PERMIT ISSUANCE,
F_ CO build's construction,and hereby Thor a,m resenmtivesofthis cit to the
above g You p Y pan CONSTRUCTION TAX
Uz (We)
forinspf parallel. ALTER OR ADD TO MSCI I.
(Wc)agrce m save,indemnify and kcep hamlle - he City of Cupertino ngaimsl
liabilitio.judgmems.co sunder awhichen y wayucrueagainamid City AIR HANDLING UNIT(TO 10,OWCFM)
of me ami permh �
AIR HANDLING UNIT(OVER IO,IXXI CPM)
Si nature of Applicant/Comms` R e EXHAUST HOOD(W/DUC) PAID
HAA OUS MATERIALS DISCLOSURE 1117ATING UNIT(TO 100,010 RTU) Dam Receipt#
Willthca licanlr forum buildin aces ant start Or handle hmardoua material
as defined by the Cupcnino Municipal Cole.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 W,m BTU) TFVL:
Code,Section 25532(a)7
El Yes 11 No VENTILATION PAN(SINGLE RESID)
,000 BTU) ISSUANCE DATE
Will the upplicamorlmm urc buildingoccupausceyuipmentnnicviceswhich emBOILER-COMP(SEE OR 100,000
tSP (QI ]VI t6T!
Incurious air c rmaminanl5 as definW by the Bay Arta Air Quality Management BOILER-COMP(OVER I W,WO BTU)
District] JUN 13 1994
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the harmonious materials requirements ander Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. I understand than CII Y act.
if the building does not currently have a mount,That it is my responsibility to notify the 1,UY6fi I11YU
cupam of the requirements which must his met prior to issuance of a Certificate of
Occupancy.
Owner reauthorised anal Date TOTAL: ISSUED BY:
OFFICE