26986APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO I�IIIi>7Nt�p1T x AI
BUILDING DIVISION APPLICATION/PERMIT L - ANICAL
BUILDING PROJHCTIDRNTIFICATION
PERMITNO.
26986 86
BUILDING ADDRESS: //�
DD /y e*• UNIT# LOT
SANITARY NO.
APPLICATIONSUBMITTALDATE
W iR. NAME: PHONE:
CO RACfOR'SNAME: LIC NO:
N/C
El
CONTROL#
/L (�. /G/ ��
/�y U
RCHI 'li ` GINEER: LIC NO:
ADDR SS:
CONIf'Acf: PHONE:
/��j
OL
y 5 G
QTY. ELECTRIC PP.RMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI1
PERMIT ISSUANCE
11 ❑ R7'1 El
LICENSED CONTRACrMvisimofaapION
(hereby affirm linerced CONTRACTOR'SD CLAR TIONcommencingwiN
gen iorceand of Divisionlof Ne Business and Prolessions Code. and my license is in
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
/1
PANELS
full LicnseClndcffect.
License Class Llc.p
UPT02MAMPS
r/Q+per sp a�
Date Canwctm
201 - IM AMPS
ARCIE FECES DIiCLARATION
1 understand my plans shall be used as public recoups.
OVER KIM AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL
Licensed Pormash n d
OWNER -BUILDER DECLARATION
SPECIALCIRCUIT/MISC,
1 hereby affirm that I am exempt from the Commctor's License Law for the
TEMP. METER OR POLIS INST.
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which inquires. permit to construct, aper, improve, demolish, or repair any strumurt
prior to its issuarm.... requires ffixtulicamforsuch amandm EleuaigrtW statement
POWER DEVICES
that he is licensed pursuant to the provisiuns of the Conimmuses License Law (Chapter
9(commencing with Section T0albod Division 3 ofthe Business and Professions Code).
SWIMMING POOL ELECTRIC
VALUATION
or that he isawain therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OUTLETS - g WITCHES-FI%TURES
not marc than five hundred dollars ($500).
❑ I.asownerofahepmp ay.ormyemployeeswithwagesuN irsolecmmp motion,
NGW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPH CONSTRUCT ION
will Jo the work, and the structure is not intended or offered for sale(Sce. 7144, Business
and Pmficadone Code: The Contractors License Law dues not apply to an ..all of
property whobuildsorimpmvesthereon, and whodees such warkhmenalforthmughhia
uwnempinyces, provided thus wchim vememsare not intended mroffered (tussle. If.
OCC. GROUP
RES. UNITS
TOTAL:
however. the building orimpnrvement old within one yearofmmpinion, theownm-
builder will It... InstanOm he Jid not build or improve for puryose of
QTY.PLUMBING PERMIT FEE
❑ Lusonerofthpsissly contrcting with licensed contractors to
FLOOD ZONE
APN
nsvuctt proje (Sss ons Code)TheConmcmr's
LicenseLm to st np wilds orimpravea Nereon,and
PERMIT ISSUANCE
whence La ) s h mens sn#smet s)nc ed urauanIt the Contractor's
p
License os
ALTER - GRAIN &VENT -WATER TA)
FEE SUMMARY
❑ 1 am ex u t under , B & P C for this reason
RACK FLOW PROTECT. DEVICE
O -
SANITARY Y N
Owner Dan
DRAINS - FLOOR ROOF,AREA, COND.
RECEIPT#
WORKMAN COMPENSATION DECIARON
ATI
SCHOOLTAX Y N
�ylhereby affirm Natlhavm cmifcnte of consenuo ulGinsurt.macenifi.11 of
�4 ons. Compensmion lnsumnceora ceniflcJ copy Netenf (Sa.38IX1, Leb C.)which
FIXTURES PER `OUP
RECEIPT#
PARK ME Y N
covers all anlo'd
P yces under this permit.
Policy p
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECH]"It
BUILDING DIVISION PF.IS
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy ishereby furnished.
GRFASFIINDUSTRL WASTE INTERCEPTOR
GRADING IEE
ElCertified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This acc iun ned ne
enot be completed ifthe permil is forohundrd doHmn($IN)
unless.)
WATER HEATER W/VENT/ELECfR
I certify that in the Performance of the work for which this permit is issued.) shall
not employ any person in any maturer so as m become subject to the Workeri
PAID
Compensation La ni.f California. Data
Applicant
WATER SYSTrAfIREATING
Data Receipt#
NOTICE TO APPLICANT: I L after making this Certificate of Exemption, you should
NEW RES IDENTIAL PLMB, SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm ilia, them is a construction lending agency for N<performance of
Ne work for which this permit is issued(See3097, Co. C.)
Lenders Name
AL.
ELECTRIC FEE
Lenderx Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that 1 have read this applicminn and state that the above information is
correct. l agree to comply with all city sial county ordinances and state laws relating to
E
PERMITIgSUANCE
MECHANICAL FEE
building construction. and hereby outboriec representatives of this dry to enter upon the
above-mentioned propcny for inspection purposes.
ALTER OR ADD TO MF.C1L
CONSTRUCTION' TAX
(We) agree m an indemnify endtoa hunnlesn the City of Cupertino against
Iiabilitieajudgmema, costa wiganx /may in any weyecerve egaivtsaid City
AIR HANDLING UNIT (TO 10,110) CPM)
i conxquenc he gr tg tis pe �� //>L ��
AIR HANDLING UNIT (OVER IO,ODO CFM)
Sign roof Appl t9 iI morn Ilam
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT LTO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Rxciptp
Will the applicant or future building occupant same or handle hazardous mamnal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT(OVER I(NI,(gW BTU)
T AL:
Code, Section 25532(n)P
❑ Yes 11 No
a'
VENTILATION FAN (SINGLE RESID)
ii a building
Will tair
BOILER - COMP (3HP OR 1 00,000 BTU)
ISSUANCE DATE
BOILER-COMP(OVER IIIg000 BTU)
co umants as by the ay Area Air Quality
hanrict? air comnminanrs as defined by the Buy Area Air Qunlity Management
District?
O
fo
I ❑Yea C1 No
1 have read Ila, haznrdnus materials requirements under Chapter 6.95 of the
California Health & Safety Cade, Sections 25505.25533 end 25534. 1 understand thus
Hits, building does not currently ha am, that it is my respomibility to notify the
"'Pa"FarPPF' of in n prim m isau//w/ce.of a Ccnifcmae of
NEW RESIDENTIAL MECH.—SQ. FT.
ell V 2 $ 199
Y
t ' / f Vr'
Uf <f(jff /r
Jt /t
I�Pt ort dn'—c agt gar Dam
,1h
ISSUED BY:
TOTAL: I I
OFFICE