26654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU 'ERTINO IBALDI. .-ELECT RI AI. PERMI'I'NO,
V ISION
APPLICATION/PERMIT PLUMBING-MECHANICAL n 6 C C
UTI
BUII,DINC UIBUILDING PROJECT IDENTIFICAI ION G v J TE
NUILUING ADURE9S: SAN 'ARY NO. APPLICATION gI1HMITTAI.DA'Di
DPep peg 7
(a yv UNIT# LOTq
OWN1iRS NAM is Ed PHONE: CONTRACTOR'S NAMii: LIC NO: t
t PIC CONTROL#
RCIII 'Cf/ENGINEER: LIC NO: ADDRESS: ❑
_0 /40 3(p S5? 77
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF,
BLDG ELECT PLUMB MECII
JUS a{p�—In, Q1Q PERMITISSUANCH El El M
LICENSED CON'TRACTORS DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
❑may HicabyarionThal l am licensed anderpmviaionaof@apter9(commencing with
4100 Section 70(khof Division 3Ol'the Business and Professions Code,unduly license is in PAN17LS qAs IIpG +0 d7cee_
CU� full farce and effect. I /
FZm Livense Class C—'%# Li 1gIQ1 UP T02f1(IAMPS cn
w6tpii
Date /—22O_AU Contvctnr� 201-1000 AMPS FIQO r✓1 ✓a'7P� .
%ONZ A TECTS D 'TAR TION /k fl SpG'.II},mR A 5/SQ.FT.
OVER IIXO AMT'S III` IB:J,
0 4,.0 1 understand my plans shall h used us public records.
FyFu1
SIGNS ELECTRICAL
M,CQ Licensor Professional OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC. I �\ L �f— C
4C)0. 1 berchy affinm thin I am exempt from he Comrmc m',License Law for the i
':a h following reason.(Section 7031.5.Business and Professions Code Any city m county TEMP.METER OR POLE INST.
which requires u permit m consumer,aher,improve,demolish,m repair my structure
�!!(Y7 prior o 14 ismance,alsu requires the applicant farmch pe.iuo fileesigned statement POWER DEVICES _.
W�a 0 Q that he is Ifamsed pursuant m the provisions of the Comment's License Law(Chvp¢r
aaoz 9(commencing with Section]100)of Division 3 ofthe Business and Professioa Code) SWIMMING POOL ELECTRIC VALUA'I"ION
_4- .,,liar he is eacn,a Oratfmmand the basis for the alleged exemption.Any violation of
OUT TLETS-SWITCIIES-
F-2a Seaion]OJLS by any applicanr(ora permit subjects the npplicannaecivil pendty of FIXTURES
mu concertina we hundred dollars($500).s�o NEW RESIDENTIAL ELI!CTR _SQ.1-1'.❑ I,asownerufthepmpeny.ormyemploymswiNwgesastheirsolecompeaation. STORIES TYPE.CONN I RUCTION
13= will do We work,and thesrrcuum is nut imendedomffned formic Sce.]I144,Business
and Professions Cede:The Contractor's License Law does not apply to an owner of
property who buildsmlmproves thereon,and whodoe.c such work himselforthrough his
on employsm provided tharsuch improvemar
enfaen.timendedorafferod Tarsale.If, I OCC.GROUT' RES.UNITS
however,the buildingor improvement is sold within one yearof completion,the ownef-
builder will have the burden of moving flint he did not build or improve Tor pufpou of 'I'O'1'AL:
sale.).
❑ I,as owncrofthe pro,any,amexclusively contracting with licereadcomumcfonm QTY. PLUMBING PERMIT FEE FLOODZONL' AI'N
construct No pmjat(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply o an owmerofproPeny whobuildsor improves thereon.and PERMIT ISSUANCE �.
who cataracts forsuch projects with acommeaf(s)hocre d!Ismuanuo the Contractor's
I.icense law. gLIER-DRAIN&VENT-WATER A
) FEESUMMARY
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT'.DEVICE OUT IDI: LS
SANITARY YN
Owner Date RECEIPTp
DRAINS-FLOOR,ROOF, COND.
WORKMAN ace COMPENSATION nctI.ARATIONnsum. SCHOOLTAX Y N
❑ [hembers'Co penrm NatnMvnce orti certeof copy them f(Scsum.ar ard,C.)whicteofh
FIXTURES-PFR TRAP RF.CIi1PT'#
Wnrkers'C.mpenswion Insurance nrmcenifiW copy there.[(Sev.3No0.Lab CJ which PARK IIEH Y N
covers.11 employees under thin permit. / GAS-EA.SYSTEM-IINC.4OUD.ETS RECEIPT#
policy# krL P 14VR BUILDING DIVISION FEES
Company r s GAS-EA.SYSTEM-OVER 4(EA) PIANCHFCK FEE
❑ CttIIfcA c.pyls hemby forandmd.
1K Cenificd Copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTHRCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR BASE TRAP SOILS FEE
COMPENSATION INSURANCE
('this mesion need not becompleted ifthe permit is for one hundred dollar(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
of hiss.)
I certify thin I.he performance of the workfor which Of,permit is issued,i shall WATER HEATER WPeENTA'LECTR
not employ my person in any m as to beemne subject res the Workers' PAID
Comaaf,wiorr Laws of California. Dram so WATER SYSTF.MiTREATING Date Receipt#
Q z Applicant
NOTICE TO APPLICANT:I L after making this Cenincem of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
2become subject to the Workers Compensation provisions of the Latin Coal you must
7 fai wah comply with such provisions tar this Permit shall be decmed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
a' 1 hereby affirm that them is a construction lending agency for the performance of
V Q'Z' Ole work for which his it mon is issued(Sea 3097,Civ.C.) TO
ELECTRIC FEE
Larder's Nates
Limen Address QTY. MECHANICAL PERMIT FEE
PLUMBING FfiE
V 1 terrify that 1 have read this application and stale that the above information is MECHANICAL FEE
ISI correct.l agree m comply with all city and county ordinances and state laws relating to PERMI"I ISSUANCE
E" huilding construction,and hereby auNmfze representatives of this city toenter upon the CONSTRUCTION TAX
V Z above-mentioned prapery for inspection proposes. ALTER OR ADD TO MECII.
(We)agree m ove,indemnify and keep harmless the City of Cupertino against AIR HANDLING UNIT(TO IO.IXO CFM)
liabilities,judgments,costs and expenses which may in any way accrue against said City
consequence of the AIR
ograntifthll.
N10.000 CFM)
6 EXHAUST HOOD(W/DUCT)
ars ofADAioUConweto. Date
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant or future building Occupant store or handle brommous material BEATING UNIT(OVER IW.000 BTU) TOTAL:
ns dcOmed by the C.,errino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(0)1 VENTILATION FAN SINGLE E SID)
❑Yes ❑Na
TE 61
Will the applicant mature huildingoecupant uuequipmemmdeviceswhichcmit
BOILER-COMP(3HP OR HO,f00 BTU) ISSUANCE DA
hazardous air comaninats as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100,00)BTU)
DOmst? A
Cl Yes ❑No NEW RESIDENT IAL MECIL SQ.IT. Y'
1 have .it the haurtam.materials requirements under Chaplcr 6.95 of the lJg�
California(health&Safey Cale,Sections 25505.25533 and 25534. 1 undcmtaoM that "I So
if the M1uilding Arta sol currently have u fencer.That it is my responsibility to ramify the
occupant of the requirements which must be met prior to issuance of a Cenificvta of 99
Ocapancy, e C/)) Ur wf 4
Owner s uvthorizW age. Doe TOTAL: ISSl1ED BY:----,�
OFFICE