26906 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO H-ILDt7 IN E EC I'RICA L PERMI"f N0,
APPLICATION/PERMIT PLUMBING-MECHANICAL 26906
RUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAATTIONSUBMTITALDATI
UNIT# LOT#
O SN MF,: P[ NE: CO OR'S NA LIC O: "C CONTROL#
ARC I"f1iC171iNGIbidd. LM NO: A / El�T
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT U B SUCH
� PERMIT ISSUANCE El El ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
21o:7 I hereM1Yu fnm that l am licensed underpmvlsi.nsof Ca ¢9(commencing with JOB DESCRIPTION
+I 100 Section 7000)of Division 3.f Ih<Business and Pmfessions Code,and an,licenu is in ppNp(,$
fun force ands .p,
F Z vI License Class Lic� 201-I" AMPS
�'jm Date Con 201-1000 AMPS
FO Z tri DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OL.-O lundersu snl:¢
ti F; SIGNS ELECTRICAL
Qy�� Licen.
�y.KQ OWNER"BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOyF 1 e affirm Na 1 am exempt from the Contractors Llcenu law for he
W3tr,m¢ following mason($enion]OJLS,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�m J which requires a parent to construct,altar,improve,demolish,or repair any structure
>�
poor o its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
t4C<0 Nd pCounselorsLicense Law at he is licenseumurnI.the provisions of the LiLCh
d pIT,
9(comm...ing with Sterna 70(hr fDivision 3 ofthe Business and Profcs.invs Code) SWIMMING POOL ELECTRIC VALUATION
_w or that he is exempt dictatorial and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
I—Za Section]031.5 by any applicant for a Permit subjects the applicantto a civil penally of
S
nm.."'mad rive hundred dWlars($5W7. SQ.FT.
N�o ❑ Lazownetvfthe progeny,nrmyemployccswithwagoaztheirsolecompemmNEW RESIDLNTIAL ELECfR ion. STORIES TYPE CONS'IRUCIION
a3e—° will Jothcilan,and The
Contisnetintendede ovcusnot apply 10 ad Business
and Professions Code:Thc Contractors License L,aw docs not apply m an owner of
property who builds.,improves lherenn,and wh.d—,,.h warkhimself.,Woughhis
hoemployees,provided that such immovententaarc not inendedoroffered formic.If, ------50C.GROUP RES.UNITS
wever,the building or improvement is sold within one yearoleomple0 m the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lxs.wnendthe propeny,amexclusivelycmnracting with licensed ronwctnrs n, QTY. PLUMBING PER11IT FEE N_0ODZONIi APN
consumer the project(Sec.7044,Business and Professions Cade:)The Contractor's
License Lovikes not apply[am ownerofproperty whobuilds orimproves thereon,and PERMI CE
whocnntrams hameld projects wish.couldcords)licensed pursuant o the Contractor's ALTER-DRAIN&VENT-
Llcenselaw. WATER( I FEE SUMMARY
❑ 1 can exempt under sec. ,B&P C for this ream BACK FLOW PROTECT. ;VICEOIITSIDI:FEP_S
SANITARY
Owner Data YN
DRAINS-Fl.00R R AREA,COND. RECEIPI'p
WORKMAN COMPENSATION DECLARATION i�•• SCHOOL TAX Y,_N
• ❑ IM1crebY:drrm that lhave aceniricam ofconcent to self-insure,or a ecrtifieute of Fl URES RECEIPTp
Workerx'Compencation lmumnce torr a aycenifred copy thertof(Sec.3800,Lab C.)which PARK PEE Y N
coversall cmployec' I e /�—p� �S Y TEM-I INC.4OUTLHI'I RF,CISION
Policy# lT_TY" / BUILDING DIVISION FEES
Coal �Ta
Q Cenif:M copy is hwy fX69-- ��YU GAS- SYSTEM-OVER4(EA) PLANCHECK FEE
(ATT, Certified copy is riled with the city inspection division. GRG1 NDUSTRL WAS NTERCEPfOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section used not be completed if Ne permit is fore.hundred dollars(SUKHSEWER-SA ARY-STORM
or less.) EA.2WFT. ENERGY FEE
I cerlifyrha is da Performance.1'he work for which this permit is issued.)shall ATt EATER W/VENT/ELECIR p0
not employ any pc.n in any name,. as to become sobject t.Ne Workers PAID
z Compensutionl.uwsof Califomia. Dam so WATER SYSTENIGRFATING Dam Rmeipt#
Applicant
z C) NOTICE TO APPLICANT:If,after tusking this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
F-' y subject become subjeco the Workers Compensation previsions of the Labor Code,you must
a >
forthwilh comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that hem is a construction lending agency for the performance of
U O the work far which his permit is issued(Sec.300.Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and state that the above information is
ureal.l agree In,comply with all city and county ordinances and state laws relating to PERM IT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives oflhis city to enter upon the
U z above"mcmioned pmpcny form"er.do puriarmaALTER OR ADD TO MECH, CONSTRUCTION TAX
(We)agree m sav unify and keep 'rlessBc Ciry of CHadmdh.bil .against
in
me scare w tryyl my way accrue against ity AIR HANDLING UNIT(TO I0,000 CFM)
in conseyuen of NiX e�
AIR HANDLING UNIT(OVER 10,000 CEM)
Si tum APA' tractor ate EXHAUST HOOD(W/DUCf)
PAID
AZARDOUS MATERIALS DISCLOS HEATING UNIT(TO 100,000 BTU) Dae RZelp,#
Willia
canr.rfumre building occupam score.r handle hazardous material
I,defined c Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT4.,
Cole,Stenon 25532nd?
11 Yes 13 No VENTILATION FAN(SINGLE RESID)
Will the applicant or future buildiageacupanl usetordwicam.hichemit BOILI?R-COME OR 100,000 BTU) ISSUANf$E ry4'[ �
q.ipmen
hazadom air commandants as darned by the Bay Ara Air Quality Management• BOILER-COME(OVER 100,000 BTU)District? Q •I
District? "'ca
❑ ENT
Nn NEW RESIDIAL MECH. SQ,PE. JAN M 2 V 7 1995
I have read be hazardous muted-1.1 requirement,under Chupter 6.95 of the
California l leelth&Safety Code.Sections 25505,25533 and 25534.I arwMersland Nat CITY
11 Uri /W�t Ls
if the building does not currently have a tem.that it is my responsibility to notify he H
Aw
rccupant of the comiremenls which must he met prior to ismrace of.Cenlrla,of
Occupancy.
Owner or authoriral agent Date
TOTAL: ISSUED BY:
OFFICE