26382 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O
CITY OF CUPERTINO BUIL";N0
-ELECTRICAI. PERMIT NO.
APPLICATION/PERMIT PLUMBINf -MECHANIC..., 26382 O O A
BUILDING DIVISION BUILDING PROJEC' IPPINTIFICATION G J O L
BUILDING ADDRESS: SANITARY NO. APPLLIICATIONSUBMfITALDATE
\ UNITS LOTS
OWN RS AMC: PHONE: CONTRACfOR'S NAME: LA-1 ALL Qonr raFnl�o' IC NO: k6J
^ ,� �, C N/C ONTROLls
In Gicilrden ARCHI'I' CT/INJGINEEft: LIC NO: ADDRESS: J ID4 N A'
CON'I'ACI'1 PHONE:
1Q7'Y. �.' `ELECTRIC PERMIT FEE BUILDING PERMI'I'INFO
MOW kN-4 G`kI�STL7bLA �-'7C�4 .5q Iq BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyz, I hereby afficn door lam licenzW underprnvisimnsnfChap¢r9(commeneingwith
V,C) Section7")of Division 3 ofine Business and Professions Cale,and my license is in PANELS
Wq'W E full force and effect
FZeC LieerMA
UP TO 200 AMPS
mQy Dam (EGN'IC. 201-IOW AMPS
XC) 1'.C,1. RATIO - SQ.PF.FLOOR AREA VSQ.FT.
OZ-0 .l�bl roc OVHft IOWAMPS
s SIGNS ELECTRICAI.Ii
�J OWNER-BUILDER DECLARATION ON SPF,CIAL CIRCUIT/MISC.
xa,OyF hereby affirm that 1 em exempt from the Counselor's License Law for the pf�+a•m¢ following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
1_-tS C"I which requires o permit an cmadate 6 abet,improve,demolish,or repair any suucmbe
et
egn3 7 prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
Iy��O that he is licensed pursuant to the provisions of the Commeors License Law(Chapter
X.
a'Q 9(Commenting with Section 7")of Division SWIMMING POOL ELECTRIC 3 bribe Business and Professions Code) / a, VALUATION
pl_yr or that he is exempt herefrom and the basis for the alleged exemption.Any violation of p{ ^ ^1
f-Z_ m OUTLETS Q Section by any applicant a Permit subjects the applicant a Civil Penalty of WWW v�I�O�
0nm mare than five hundred dollar($5100).
. ❑ l,mownerofthepropuntye P Yeeswithwag seitompnsation, I NPWREIDENTALELECIR _SQ,FT.
STORIES TYPfCONSTRUCTION
9!3_ will Jo the work,and the someone ixnnimenacd oroffcrcd forsale(See 7W,
Business
and Professions Code:The Contractor's Liecnso Law does not apply to an owner or
property whobuildsorimproves thereon,and whodoessuch workhmealforthroughtis 4u
ownemployecs,providWthxtsuchimprovomautsurenmtintendedoroffeedforsule.If, C OCC.GROUP NES.UNITS
however,the building orimpowemem is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
aide.).
(:I I,aabwnertone pnpeny,am exelaaivelynanneating withneenaea eontremmom QTY, PLUMBING PERMIT FEE FLOODZONE npN
tons.,the projee(Sec.7044,Business and Professirms CWC:)The Connector's
.Jeanie Law doexrmripplymanownerofpmperrywhe baildsmr improves thereon.and PERMIT ISSUANCE
whocantnets for such projects with aconnemmt(s)licensed pursuant to the Contractor's ALTER-DRAIN&VPN'(-WATER(FA)
Licensee Law. FEE SUMMARY
❑ lam exempt under S.. ,B&P C for this.axon BACK FLOW PROTECT.DEVICE OUTIDL ..
SANITARY Y_N
Owner DamD.C
AREA
ROOF, ,C. RECEIPT N
'
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, / S- X
❑ IM1e.ny affirm thmlhave ncenifcxm ol'cbnsent to self-insure,mrucenifcme ml ECIi P1'b
FIXTURES-PER TRA.'
s L�ITIC W S��k GAS-EA.SYSTHM-1 INC.4 OUTLI TS \/ "I' liKF E Y N_
Wnrkvre'Cnmpenswion Insurance nraocnil7W spy therwf(See.3800,Luh CJ which /-
era all employee's under this permit. RCCIiIPI'N
Policy
C800E DIVISION FEES
Company �Yb (k.l GAS-EA.SYSTEM-OVER 4(EA) P ➢:
❑ Certified copy is hereby fumishcd.
Certified copy is filed with the city inspection Division. ra Fat I
GREASE/INDUSTRL WASTE.NTE EP`EOR DJ LTE IffAVI FTE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETIEAP -- SOILS FEE—"
COMPENSATION INSURANCE
(TInsaectiouneed eC ed ifthe pernir�neumdreddollan(5100) SEWER-SANITARY.STORM EA.20ki ENERGY IEE
or lass) �{{
.cenify thmi he fm Ce rk tbispe is issued.l shall WATER HEATER W/VF.M'7ELEC1'R
not cmpiny w arson m inter 6 to come eat to the Workers PAID
O z CAbmpeui^mio s i 'yi Du WATER SYSTEM/TRHATING Dam Recent#
O pP Cosa
N(YTICIia11 ATFL ANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIA I.PLMB. SQ.FT. TOTAL:
V) bccmmc suhject to the Workers Compcnmthm mus
provisions mf the Labor Cade,you t
�i > fonhwithcomply wuhimch provisions m this penuitdalt be deemed revoked. BUILDING FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I herebyxffirmthinflu eisx construction lending agency for me perfortmme of TOTAL: ELECTRIC FEE
O the work for which this pemm is issued(Sec.3097,Civ,C.)
Leaders Name PLUMBING PEE
0 U Leader,Address QTY. MECHANICAL PERMIT FEE
>a W4I cenify mat I have read handles this application and state at the above information is MECIIANICAL FEE
r.et. l agree to comply with all city and county ard'mances and state laws reining to PERMIT ISSUANCE.
� building Construction,stat hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
V y above-nmmioncA pmpe or in ccinn pwpnacs. ALTER OR ADD TO MCC...
G (We)ugac m e mdems ry and cp hu e s the City of Cupertino against
liahilitia,juagm ostsan xpen s ich xyi any way ecerueagainn said City AIR IIANDLING UNIT(TO IO,fxx1 CFM)
.naeyaenc nn grams bn a p
-,'31 AIR HANDLING UNIT(OVER 10,04))CFM)
"Ielime of App' ontnctor Dam EXHAUST HOOD(W/DUCI)
PAID
If RDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant scam or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino m
ino Municipal Ca ,Chapter 9,12,and the Heahh and Safety
Chile,Section 0Yes 25es VENTILATION FAN(SINGLE RESHH
So
WilHhm licantarfmme huildin•occur BOILER-COMP(3HP OR 100,000 BTU)
ISSUANCE DATE
pp 6 pmt useeyuipmem ordevices whichemil
Icmmdaus airemiumooams as defined by the Bay Area Air Quality Management BOILER-CAMP(OVER 1811,800 B'[HE
Disdictl
❑Yes Ne NEW RESIDENTIAL MECH. SQ.FT.
Ad ush a miuls requirements under Chapter 6.95 of the
CWifn
Sections 255(13,25571 and 25574. 1 undersand that
iftn, It t smy risibility m notify me
<uPhie at P or t a of a Certificate of
rin
nr author cd Dam TOTAL: BY:
OFFICE: