26758 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x IL UNU-ELECTRICAL PERMrr NO.
APPLICATION/PERMIT PLUMIIING-MECHANICAL 26758[ O
BUILDING DIVISION BUILDING PRQJECI'IDENTIFICATION o J v
BUILDING ADDRESS:/D t SANITARY NO. AI'PLICATIONSUHNU TALDATe(o l $cerH< sed 4'Y6 - goy
UNIT# LOT ")^Iq—q
OWNERS NAM{;;ly)Q 4_5a PHONE: ��D CORI'NACTOR'S NA LIC NO: N/C CONTROL#
rRCHITECI U/EIdNGINHERV ICNO: ADDRESS: a ❑
CONTACT: PHONE: "
QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
BLDGto.l'[ \ PLUMB MGCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT]AL It R 1
Qy.Z Ihereby off n Na l am licensed underpmvisiom of Chapter9(commencing with
a�100 S«tfare.m0)of DivisianJofthe Business end Professions Cade.and myli<enu is in PANELS
q U full force and effect.
6Z, license Class Lic.# UP TO 200 AMPS
in Q y
Data Contra., 201-1000 AMPS
Z FOyz ARCHITECTS DECLARATION OVER IfAXIAMPS SQ,IT,FLOOR ARG $/SQ.FT.
OZ—Q I undersumd my plans shall b,used us public Tatmads.
eeN _ SIGNS ELF.CTRICAI. 2
Q,L ,4 Licensed Professional
O (�
�owu OWNER-BUILDER DECLARATION SPECIAL CIRCUII'/MISC.
KOiO 1 hereby afrirm that 1 eon exempt from the Conmacmrs License Law for the
W3LLy following reason.(Section 703 L5,Business and Professions Cade:Any city or county TP.MP.METER OR POLE INST.
N11y1 which requires.permit 10consumer,.hartimprove,demolish,moelmatinysuanme,
�>. to its issuance,also requires then applicant for such permit rile a signedstatement POWER DEVICES
prior y pp pemti
uJr 00m It.,he islicensedpursuata to the provisionsof the Cmarwors License Law(Chapter
V olt 9(commencing with Section 7")of Division 3 ofrhe Business and Professions Code) SWIMMING POOLELCC'IRIC VAI UATION
ry'^y or that he it exemptbysun,therefrom and tfr.bu.iscthe
cesmalleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
CZQ Section than03 v eundredicanlrsB$50nniuubjenstM1e appl.........civil penahy of !/
$ not metre than rof hundred fired dollar myem). NEW RESIDESTUAL ELEM _SQ.IT.
e'FQ ❑ Laxowrk,unheestracy,ormyemployedorofend forsalei.mle 0CUL,Bsiness STORIES TYPE CONSTRUCTION
will JothewonsCde:The Curmadotitneneese afwdocar eale(Sec.7o94,Business
and Professions Cade:'pr Contractors[.leans Law docs not apply to an"(owner iof
t
progenywhobuprovid Ulovesthermnand whodoessuchwork M1imeelfanM1rmic.Ie
own employees,pingor improvement
earofJopletiod meow. .- OCC.GNOUI' RES,UNITS
however,the have
the
bur improvement is sold within one year ofimpro,tion,the owner- TO'1'AI
builder will have rM1e burJen of proving Nm he did not build or improve for pmlwu
ale.).
❑ PLUMBING PERMIT FEE FLOOD ZONE APN
Conswct the project(Sec.7044,Business and Professions CWc:)'Me Contractors
License Lawdoes not apply wanownerofprogeny who builds ooimprovesthercon,and PE TISSUANCE
who Cataracts forsuch project,with.Commshanii)licensed pursuanno rhe Contracwrs Al,TER-D &VENT'-WA'TEN(li
I.Iceou Law. PEE SUMMARY
—�.- ❑ l am exempt umler sec. ,B&P C tar this r I E FEES
BACK FLOW PROTI: 'DEV SANITARY Y N
Owner Date RGCEIPPp
NS-FLOOR.NOO .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ ers'Coyaffi.m thatlhranceave a oracerieificate mnscnno Of(selfS u380OLbC.) f RECEIPT#
Wnden'Compeneation Insurance oreceniried copy thereof(S c.3A00.L.bCJ which PIX(' RTRAP PARK HE Y N_
Covers all employee's under this permit. S-E SY C. OUTLETS RECEIPT#
Policy# BUILDING DIVISION HER
CompanySYSTEM-O ER 4(EA)
❑ Certified copy is hereby famished. N CK FEF,
❑ 6RA6 91SIKWASTE INTERCEPTOR G NO FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRA B FEE
COMPENSATION INSURANCE
(Ifiis section need,im be completed lithe permit is foronehuodred dollen($100) EWER-SANITARY-ST RM FA. OFT. ` ENERGY 'E
tar lees.)
I cenify that,the ptrfonynmann the work for ecic a subject o(lie Workers'
WA GTER W/VfiNl'/ELECTR
not employ any person in any mann,r so as m become subject to rbc Workers' PAID
Z Compensation Lows of Celifomia. Dam WATER SVS NI?A'HNG Date Receipt#
Applicant t
V) NOTICETOAPPLICWorkerIf.s after Compensation
this
ovisiosofthficate of e aborod.you you mull NEW RESIDENTIAL SQ.PT. TOTAL:
t+ � hettwithcme replyct the Workers Comms or
this Permit
be eemed evoked, must
tai 7
Forthwith comply with such provisions onhis permit shall be deemed revoked. B I�ILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC HE O
7 z I hereby affirm that there is a Construction lending agency for performance of
V O the work for which Ilia permit is issued(See 3097.Civ.C.) TOTAL: ELECTRIC HE--, r
Lender's Name
Leaders Address QTY.' MECHANICAL.PERMIT FEE
PLUMBING FEE
L) I cenify that I have reed this application and state that the above information is
correct.]agree mentality with.][cityand countymnlirunces andswte lawarelating to PERMIT ISSUANCE MECHANICAL FEE
L,0 building construction,and hereby authorize representatives ofthis city reenter upon the CONSTRUCTION TAX
V 7 above-mentioned pmperry for inspection purposes. ALTER OR ADD TO MECII.
[� (We)agree m save,mdemalfy and keep hnnnlees the City M CnIsmina against
liahililies,judgmems,costs and expenses which may in any way accrueeguin
an y AIR HANDLING UNIT(TO IQ000C1oM)
in<onsequepc<afmaKrantingofthiscamn Iy
�,/ �S Q AIR HANDLING UNIT(OVER 10.001y,CPM)
Sign ,ppliAcurn/Cmamaacam, Dam EXHAUST HOOD(W/DUCT) PAR)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I01y)00 BTU) Dare Receipt#
Will the until cant or future building occupant store or handle hooardous material
ns deemed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety I HiATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 255 532(e)I 11 No ENT
11yVILATION PAN(SINGLE RESID)
Will dmapplicent or fummbuildin8occupenr useequipmcmordeviceawhich emir
BOILER-COMP(3HPOR 100,000BTU) ISSUANCE DATE
notorious air contaminants as defined by the Bay Are.Air Quality Management BOILER-COMP(OVER ITAI,wo BTU)
iatrim'1
11P p D
Yee ❑No NEW RESIUEN'I'IAI.MECH. SQ.Ff. /W
I have rend the humrdous materials requirements under Chapter 6.95 of the JUL + 199
California Health R Safety Code,Sections 25505,25533 end 255]4. 1 understand that �]
if the building docs not Currently have a tenant,that]t is my responsibility m notify the 4
occupant ofthe requirements which must he met prior to issuance of a Certificate of /s
Occupancy. Vit !'fes
Ut-
Ownc,ta,mi mEr, idecm Dam TOTAL: ISSUED BY: �L��Jt�/F I
OFFICE