26044APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
BUILDING - ELRCA IHCAL
PLUMBING - MECHANICAL.
BUILDING PROJECIADENTIFIC,AI'ION
PERMIT NO.
Ti60�I
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Bull DINGADDRESS :
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SANITARY NO.
APP/LICATIOON�SUBMIITALDATE
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UNIT#
LOT#
Y/CONINT\RO
OW 'RP. S NgDi : PIIONE: ��
CON'I'RACI'OR'S/NAME : 1 & ICNO:
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N/C
❑
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ARCI II ILUI Ad`4GINEER: LIC NO:
A D
(!(�y,I
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CONTACT: PHONE:
'
QTY.
CLF.CTRIC PERMIT
FEC
BUILDING PERMIT INFO
BLDG FLECT U B MECH
PERMIT ISSUANCE
❑ 0 Pk ❑
LICENSED CONTRACTOR'S DECLARATION
Ih700fimfirm Natl and of he sedunrs and rofesions Coer and mmecense wiN
Section T0(p) of Division 3 of the Business end Professions Cade, end my licca. is in
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
fail Force and e ect,4 / e,�
Licem Clots r hic.p D
Dam Contracmr
DP TO 200 AMPS
201 - 10011 AMT'S
ARCHITECTS DECLARATION
I understand my plans shall he used as public records.
OVER I" AMPS
SQ. PT. FLOOR AREA
5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional "
OWNER BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I sm exempt from the Cmdommes License Law for she
TEMP. METER OR POLE INST.
fallowing reason. (Section 7031.5, Business and Professions Cade: Any city mcoumy
which requires a permt to construct, alter, improve, demolish, or repair any structure
prior o its issuance, also requires the applicant forsuch permino file a signed statement
POWER DEVICES
that he is licensed Imummtmthe provisions.(Ne Craro mm's Licen. law (Chapter
9 (commencing with Section ]000)af Division 3 ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. My violation of
Sect ion]031.5 by any npplieam far u pennitsubjecuthe epplicantto u civil penalty of
/71 -i
-
OUTLETS - SWITCHESFIXTURES
imam thanfive hundred dollars ($SW).
n❑ Les r,mdthe perty,nrmyempendeeswiNcandfm Neir.le camprnsiiess
NEWRESIDENTIALELECIR_SQ. PT.
`7f�
STORIES
IYPECONSIRUCfION
will dathe work, and theswmureis notiutrndcde offered Tonle(Sec. 0014, Business
and Professions Cede: The Contractors License Lew does not apply to an owner of
propenywhobuilds or Improves Nerenn, and whodmssuch workhimselfonhrough his
nemployees,provided Natsuchimpr ementsmnotintendWorofferedfors e. If,
OCC.GROUP
UNITS
TOTAL:
however. the buildingor improvement is sold within use yemofcomplemat, lheownmr
builder will have the burden of proving Nu he did nm build m improve fm pappose of
QTY.
PLUMBING PERMIT
FEE
s le.),
❑ I, as ownernfNe Property,amex<lusivelyamtrecting wiN licensed amuecmn res
1'LOOD ZONE:
EA"
construct the Project (Sec. 7044, Business and Professions Cade) The Contractor's
Lice ase l.uw does nm apply m en ow nn o(propcny who bu Ids or i mpmvp Hereon, end
PERMIT ISSUANCE
whocanorots(arsuchpmjectswiNaconimctm(s)licensW puraomtm Ne CommdolsAL'IP.R-DRAIN&VENT-WATER
License Law.
(EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C far this resson
BACK FL PR EVACF.
DRAINS- .W ,R F, AREA, GOND.
Ink
t '
IDE ...
BY Y N
RECEIPT#
II LTAX Y_N
RE.CEIPI'#
Owner Dam
WORKMAN COMPENSATION DECLARATION
I hereby afion that l have a certificate of consent set f -insure, or a cenificale of
em'Compensation Insurance or acenifW copy Nereof(Sm. 38th, Lab C.) which
avers allemylpy{e'e ttJtdeC this petmiL
Policy# F/v/n HDIll
-
FIXTURES -PE TRAP` 1 -� t�
—
itZ
ARK :E Y N
RECEIPT'#
GAS - EA. YSTEM-I INC. 4OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. YSTEM-
PIAN HECKFEE
❑ Certified copy is hereby banished.
GREASEANDUSTRL WASTE INTE.RCItOR
_
GRADING FEE
Cer ifiW copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS PEEi
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200F1'.
ENERGY PER
This smion need and becompltMHNe permit is for ane hundreddo11ms($100)
mless.)
WATER HEATER W/VENDELECTR
I certify that in the performance of Ne work for which this Permit is issued,)shall
not employ any person in any manner so as to become subject m the Workers'
PAID
WATER SYSTHM/IRI?ATIN(1
Compermlion Lawsof Califomia, Date
Dme Receipt#
Applicant
NOTICE TO APPLICANT: If. after making Nis Ccnificamof Exemption, you should
NEW RESIDENTIAL PLMB. SQ. PT.
TOTAL:
became subject to the Worker's Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or this pemtit shall he deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performance of
the work for which this pemtit is i..W (See. 3097, civ. C.)
Lender's
TOTAL:
4
ELECTRIC FEE
Name
Lenders Address
QTY.
MECIIANICALP17RMIT
FEE
PLUMBING RJR
MECHANICAL. FEE
1 cmify that 1 have read this application and also, that the above information is
roman. I agree to comply withO city and county ordinmtcea and sum laws relating m
PERMITISSUANCE
building construction, and hereby outhorice representatives of this city menrer upon the
above mentioned property for inspection purinses:
ACI ER OR ADD TO MSCI I.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep hamdess the City of Cupertino against
Iinhilitics,judgments, costs and expenses which may in any way acerae against mid City
AIR HANDLING UNIT GO 10,000 CFM)
in consequence of the grouting of Nis permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature of Appluma/Conuamor Date
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT GO 100,000 BTU)
Date pt is
HAZARDOUS MATERIALS DISCLOSURE
W ill the applicant or future building mcupam store or handle bamdous material
as defined by the Cupertino Municipal Cale. Chapter 9.12, and the Health and Safety
1I FA'TING UNIT (OVER IfN),(#q BTU)
TOTAh:
VENTILATION FAN (SINGLE RESID)
Cede. Section 25532p)?
❑ Yes ❑ No
BOILER - COMP (3HP OR 100,000 BTU)
ISSUANCE DATE
�g p I D
Y" G1
ceswhiJ=nl
Will air etaicunmrfumre defined
d by die rice mu Air Quality
hazerdmaa air comaminanu u defined by the Bey Arca Air Quelily MenagrnKBl
DindxtT
BOILER -COMP (OVER 100,MD RTU)
❑ Yes ❑ No
1 have rend the IunuNous mumnals requirements under Chapter 6.95 of the
JUT, s Q 9 199 4f
ro til #7 yxJ' Lp
NEW RESIDENTIAL MECH.—SQ. FT.
California health & Safety Cede, Sections 25505, 25533 and 25534. 1 understand that
ifthe building does not currently have a mama, that it is my responsibility to notify the
occupy f the n quiman, w �mu t be mp prior to issuance of Cenif le
°` V! a
CITY Vh f,.vrrH1 Hvv
ISSUED B .
Caviler or omhorixd gent Due
TOTAL:
OFFICE