26297 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 7i.P.LELTRI PERM]'I'NO.
APPLICATION/PERMIT PING PROD CT IDEANICAL 26297
'
BUILDING DIVISION BUILDING PROJECT IDF.N'1'IfICATIfIN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
U UNIT N LOT
O ERSNAME: PHONE: CONTRACT'OR'S NA ME: LIC NO:
E N/C CONTROI,N
cDty -/-/()Jr Q 1-00;4J 57 /
• ARCHITECT/ENGINEER: LIC NO: ADDRESS:
/ /l/ /JPi
CON'I'ACI': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACI OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Owz Ihercbyaffinmth®l not licensedunder provisherom CTapter9li,cr.nciag with
nJ00 Section 7000)of Division 3 of the Business and Pmfcssions Cade,and my license is in PANELS
OF fuIlfo�ce end cifcc. /� /• (s
IzW I,iccnsc Clas- - Lic.if S/Z��3 UPT0200AMPS
m Q d Dam Contrector 201-1000 AMPS
l—,,z ARCIIIECTS ARATION OVER 1000 AMPS 0 �, p'fQ.F1'. L R t $/SQ. f.
lundcrsandm plans shall use obs. I r t f h ham. IL1'�/A
F,yF-uJ � SIGNS ELECTRICAL ^fI'�'
Q CQ License) a"'"al OWNER-BUILDER DECLARATIONp1 Ips SPECIAL CIRCULEMISC. \ ) ��/J .Il� 1 R
Jx2a0a O I hereby affirm that I em exempt from the Contractor's License Law for the _
W3ati following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�0J which require..a permit to construct,alter,improve,demolish,or repair any structure -
K�2Q7 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
rG p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC 1Lxpa 9(commencing with Station 7000)of Division 3 of the Business and Professions Cade) VALUATION n
W_rn or he is exempttherefrom and the basis for theslle,ed exemption,Any violation of D�L(L--
$,Q Section 70315 by any upplicant for apennit.zuhject,the uppli<annn a civil Penalty of OUTLETS-SWITCHES-FIXTURES O
x nm more than f ve hundred dol Inrs(8500).
ce nt ❑ I,msowneroftheMMny,ormyempiuy withwagcsavhcirwlcc=m mfon. NEWRESIDENTIALELECIR _SQ.FT. VTORIES TYPECONSTRUCI'ION
y3— will do the work,and the svucmrc is not imendedaraffered for aele(Sec.7W.Business
and Professions Cale:The Commutes License Law does not apply to an owner of
property who bui lds or improves thereon,and who does such work himsel for through his
employees,pmvidrri that such improvementsarcnut intendedoroffemd foesale. r-
OCG GROUP EA
bull&, the building oder mvemcntishm within use yearofimproe turtheowner- TOTAL:
builder will have he burden of proving that he did not build a improve fur puryou of
tele.).
❑ Las owner"fine property,am exclusively convecting with liveredcontrammior QTY, PLUMBING PERMIT FEE FLOOD ZONE
construct the pmjea(Sec,EWA,Business and Professions Code)The Contractor's
License Lawdocsnot apply loanownerofproPenywho builds or lmprovesthereon,and PERMIT ISSUANCE
whocontmca
forsuch projects with a contractors)licensed pursuant tat the Convectors V
ALTER-DRAIN& ENT WATER IiA
License Law. ( ) I FEE SUMMARY
❑ 1 um exempt under Sec. R&P C for this reason BACK FLOW PROTECT.DEVICE UTSI UE PEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RLCLIPT#
• covers WORKMAN COMPENle ofco DECLARATION SCHOOL TAX Y N
❑ ers'Co penrmon Insurance a.cmcoR consemmaelf-ee38or Lid, i.)white nR RECEIPfN
FIX'1'URCS�PGR TRAP
Workers'Cnmpensarion lwuranemracenifed copy thereof(Sec.38IXk Lab CJ which PARK PEE Y N
all employees under this Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RVCEIPT k
Policy N BUILDING DIVISION FRI3
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FRE
❑ CenifieJ copy is bcieby famished.
❑ CenifiW copy is filed with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADINGFLE
CERTIFTCATF.OFEXEMPTIONFROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need not be completW ifthe permit is furore hundred dollars(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Ices.)
I certify then in the performance of the wark for which this permit is issued,l shall WATER HEATER W/VENT/ELEM
not employ any person in wyCnlifamim ,so as no ct to the Worker' PAID
Compensation Lx sof a Datate` cy�e9 WATER SYSTEM/TREATING Dam Receipt#
O z Applicant O✓ $
z 0 NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
1--' (q became subject o the Worker's Compensation Provisions of the Labor Code,you must
� ? forth with comply with such Provisions or this permit shell b<deemed revoked. BUILDING FEE dU
1 (❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE ss�
z Iherebyafr,.Nat there is a construction leucin,egerey for the performenceof TOTAL: ELECTRIC FEE
U O the work for which his permit is issued(See 3097,Civ.C.)
Leader's Name PLUMBING PEE F lenders Address QTY. MECHANICAL PERMIT FEE
0 U 1 cenify that 1 have mail this application and sum that Ne above information it MECHANICAL FEE
>. Da aroem.l agree to comply with all city and county oNinmces and state laws relining to PERMIT ISSUANCE
buddiagconstruction,and hereby authomc represcrativea ofthis city no ennerupomhe
U z shove-mentioned Property for inspection ALTER OR ADD TO MECH. CONSTRUCTION TAX
pec purpose,.
(We)agree m save,indemnify and ke p may m a the City of Cupertino id City L pp
r Iiabilitics,juJgmen4cosaandeapcnscsy4 hmayinanyweyxcmeagainstsaidCity AIR HANDLING UNIT(TO 10.000 CFM) 6('
in umuque the granting of this C AIR HANDLING UNIT(OVER 10.00(1 CFM) 00
mreof Applican(Cantrectm EXHAUST HOOD(W/DUCD PAID �Z
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN),000 BTU) "°" Retthpl N
Widdicapplicant or Route building occupamsaac nr handle hazardous maenat HEATINGUNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I lealth and Safety
Cade.Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
I- 'tl S�SkUA�qNCpD
E DATE
Will the applicant or future buildingocculam usecquipmemordeviceawhich noir BOILER-COMP UIIP OR 100,0(10 BTU) Y'i (pI,
obamrNous air contaminants as defined!by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BBIT) p') ,a
District?
f 1:1 Yea ❑No NEW RESIDENTIAL MF,CIT SQ.FT. 22 199/J
LO.ne,mmilassueditipan
ave read the hazardous materials requirements under Chapter 6.95 of the �1" �sN IJJNY'
i1undersandNmilding does not currently have a tenant,that it is my responsibility to notify the GIIY ser ,uran I HvUt of the requiremems which must be mel prior to issuance of a Certificate of Dam TOTAL: ISSUED BY:
OFFICE