26406APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HOI .PRI(IJENli -ChI' IEl1E"NR'1I'1CFAICIATIONs j;
APPICATION/PERMIBPUBNG.MECHNICAIBUILDING DIVISION 1
PERMITNO.
26406 40v
BUILDINGADDRESS:
SANITARY NO.
APPLICA'DUN DATE
0 1�N�-+v✓ LOT
ySUBMIT1'AL
";,—f V
NI
OWNIiRS E: P NT��
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CON 9'ROLM
f ARCHDIiCI'/E GINEI:R: LIC NO:
ADDRESS: -
CONTACT: PHONE:
QTY. l 1ELECI'RICPERMI1` FEE
BUILDING PCRMIT INFO
ELECT PLUM M 21
TW'�1
PERMIT ISSUANCE /'
LICENSED CONfRACfOR'S DIiCLARATION
1 hereby affirm that I nm licensed onderprovisinns nraq...9 (commencing with
APPLIANCES - RESIDENTIAL
-
LOB DESCRIPTION
Section ]000)of Divixion3 of the Bnsinese and Profeseione Code, and mylicenu is In
full force and effect.
PANELS
/ �1
1 '
Licenu Cana Liap
UP TO 200 AMPS
1`/�`
h V�%✓
Dae Contractor
201 - ["AMPS
ARCHITECT'S DECLARATION
I nnderstund my Plans shall he usal in, public mcmrds.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SI'L'CIAL CIRCUIT/MISC. _.'sss
1 hereby that I am exempt from the Contractors License Law for the
TEMP. METER OR POLE INST. '
r.affirrionSe
following reason Section Business and Code: Any city
which Omeet5,
e .0. demolish.
const to mtrewcL ulmq improve, demolish, fi rcpuig any swcturc
smart a
its the
itsensedralso
issuance, for file a stateroom
POWER DEVICES
the Comactiuo
prvisiosocant
that hn
nt to the License
Licenu Law (Chapter
La
Na he is licensed pursuant the provisions of the the Business
9 (commencing with Section Division 3of the 9usiness anJ Professions Code)
SWIMMING POOL ELECTRIC
VALUA'f10N�
or that he is exempt therefrom and the basis for the alleged exemption. Any violationof,
Seclinn 7131.5 by any applicant Into permit subjects the npPlionnt to n elvll penalty of
O'1'LETS-SWU CT IES -FIX3'ORES
then five hundred dollars (5500).
.uownerofthe Pnspeny.ormyemployeen with wagesastheirsolecompensation,
t
NEW RESIDENTIAL ELECIR _SQ. F'r. '
J -ST RIIISL-/ d
MPECONSIRUCTION
wiildo work,.nd thea ecmm is not intealmoroffered fortitude (Sm. 7W4, Business
and Prokseio e, CoTh
de: e Contractors License Lw does not apply m an owner of
proprly whobuildsm improves thereomand who does such workhimselforthrough his
ownemployees,providedihatsachimpiovementsarenntintendedoroffemdformle.If,
� r-� f^-'
1U � P V �-= Ih
G
RF...UNIT5
T DAT
however, the building or improvement is sold within one yearofeompinion, the owner
builder will have the burden ofproving that he did not build or improve for purpose of
-
QTY. PLUMBINGPERMIT t' .'T17E
FLOOUZONE
sale.). -
❑ Las ownero0hc propeny,nm exclusively conuucting with licenscJ contmclors to
APN
continual the project (Sec. 7144, Business and Professions Cord.) The ConWnor's
ot apply loan marrofpceperty ximbrildhanimproveseon, and
thre
PERMIT ISSUANCE
who contractsforsuch projects with acontmcmr(s) licensed pursuant to the Conuaaor's
License Law.
ALTER (EA)
FITSUMMARY
❑ I am exempt unJer Sce. B & P C for this rcuson
BACK FLOW PROTECT. DEVICE
UTSID . MTS
SANTI'ARY Y N
RECEIP#
Owner Dam
DRAINS - ILOOR.ROOFABPACOND.
, , .
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a certificate ofemcsent to self-irmum, or a certificam of
Workers Compensation Insurance orawnified copy thereof(Sec. 3800, Lib C.) which
SCHOOLTAX Y N
RECEIPT p
FIXTURES - PER TRAP ��
PARK PEE Y_N
covers all employee's under this permit..
Policy#
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECI?IP`I' #
BUILDING DIVISION FLES
Company
OAS - EA. SYSTEM-OVER4(IiA)
PLANCHECK FEF.
❑ Cenifred copy is hereby famished.
GRIASE/INDUS'IRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenified copy is filed with the city inspection division.
CERTIFICATE OFFAEMMON FROM WORKERS'
COMPENSATION INSURANCE
GRFASETRAP
SOILS IEE
SEWER - SANITARY - STORM FA. 200FT.
ENERGY FEE
This seaionnecd not be completed ifthe permit is frrone hundred dollars ($100)
or less.)
WATI7R HEATER W/VENT/ELRCI'R
I coni ry that in the performance of the work for which this permit is issued. I sh.11
so
not anploy any person in any n as to hecome subject lu the Workers
PAID
Compcnsaiomliwsnf C.lifomia. Dom
Applicant
WATER SYSTEMTREATING
Date R«elpt#
NOTICE TO APPLICANT. If. after making this Cenificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
fonhwitb comply with.uch provisions or this Permit shall he deemed revoked.
BUILDING ME
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the perfmmance of
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
L
-
ELECTRIC FEE �•
Under 'sAddress
QTY. MECHANICAL PERMIT `/ FEE
PLUMBING FEE
I scmfy that I have read this application and nam the, the olmve information is
ing to
correct. Iagrc tocomplywithallcityandcountyoNinmec ndnam lawJ1,0
PF.RMITISSUANCIi ��
MECI IANICAL FEE
builiingconstraction,end herebyamhorim representatives ofthis city to ent
above-mentioned properly for inspection purposes.
(Wc) mgr« to save, Indemnify nod keep hamless the City n sgai
A OR ADD TO MECIi.
CONSTRUCTION TAX
Hp NDLINGUNIT(T010,a10CFM)
in conus en of lheg gat this permit.
A111 HANDLING UNIT (OVER I0.OU0 CFM)
,tiltgnu cr ppllc.m/Commetor DO
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT(T0100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future Willing occupant score or handle haeardous maimmil
us defined by the Cu sammor Municipal Code, Chapter 9.12, and the Health and Safety
IIIATING UNIT (OVER 100.000 BTU)
TOTAL.: -
VI:N'1'ILATION PAN (SINGLE RESID)
Code, Section 25532(a)]
❑ Yes 1:1 No
Will lheapplicant or futtembuilding«cupent use equipmentordeviceswhich emit
BOILER- COMP (3HP OR 100.1100 BTU)
ISSUANCE DATE
horrendous air contaminants as defined by the Bay Amu Air Quality Management
District's
BOILER-COMP(OVER 100,00) BTU)
❑ Yes ❑ No
NEW RESIDEN'T'IAL MECH. SQ. I9',
1 have read the hnsNcus materials rcquiremems under Chapter 6.95 of the
ddyy
C {�
Cilifomia Health & Safety Code, Sections 25505, 25533 and 25534. I undersand that
if the building dcev not currently have o tenant, that it is my responsibility to notify the
occupant of the re,mo n i nts whldt must he met p,lot Ire Iraccur. a of a Cenificm. of
pe
NA �
cupancy.
Occupancy.
I
ISSUED BY:
Owncroraaborimdageot Dam
TOTAL:
OFFICE