26706 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EELI RACAL PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL IT O C
BUILDING DIVISION BUILDIN:PRIIdECf IDENTIFICATION L 6
BUILDING AUD � /� N`Q SANITARY NO, APPLICA'110N SUBMRTAL DAT[
\0\1eapzo UNITM LOT I h
OR NAME: Egsfil � C A OR'S NA � LIC NO: NIC CONIROLK
f�T
•ARCHHECT/ENGINEER: LIC NO: ADDRESS: .41 , ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑ 1r-10
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereb (firm that lamliansedunder fCTu ter9(commemart JOB DESCRIPTION
p�z ya prdPronW p eisin
x00 Sanlorceand fDlvision J.l Oa Business and Professions Codc,and my license is in PANELS I v
<- full Ponce and eft UP TO 200 AMPS
F Z ly Licca - Confirm
ir
,Z W Dam s Lic.If IOr 20I-IOW AMPS
ZOy� ARCHITECT$DE A ATION OVER IOWAMPS \�.M�R S/SQ,IT,
OZ-0 I understand my plain shall be used.public records.
P to F'w SIGNS ELECTRICAL
KQ j Licensed Professional
ZCQ OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyO I hereby affirm that I am exempt from the Contractors License Law for the
W3LL, following mason.(Section 7031.5.Business and Porexsions Code:Any city.,county TEMP.METER OR POLE,INST.
C< which requires a permit to construct,alter,improve,demolish,or repair any structure
}� prior m itissuance.also requires the xMiieant for such pcond to file o signed sutemmt POWER DEVICES
WCpO that he is licensed pursuant to the provisions of the Contractors Licrose Law(Chapter
d2 4c with Section 7")of Division Sof the Business and Professions Cade) SWIMMING POOL ELECTRIC N
(ammenungwi
y)_y motionan 7031.5 by nhcmfrommdthe hermits subjects
is thedexempti to civiny l Penalty of OUTLETS Section 7031.5 by any applicamforapermit subjwts the applicant to,civil Penalty of FIXTURES ,00r N
S 0 not mom than five handled dollars($500).
z F_o ❑ I,asawnerofthepropcny,orm em to eeswithwa esaaheirsolecom NEW RESIDENTIAL ELEC SQ.FT.
Y p Y 8 pBusinen, TORIES TYPE:CONSTRUCTION
a3=°
will do the work,and the structure is notimendedoroffercd forsulc(Sec.]044,Business
and professions Code.The Contracmr's License Law docs not apply m an owner of
prnpcny who builds or improves thereon,and who dues such work himself orthrough his
employees,provided that such impmvemenuare not immadedorofferedfarsale.If, I V OCC GR P RES.UNITS
however,the building or improvement is sold within one year ofeirmpletion,the owner-
builder wil I have the burden of proving that he did and build or improve for purpose of
sale.).
❑ I.asownerofthepmpeny,amexclusivelycontmctingwithlicensedconv canto QTY. PLUMBING PERMIT FEE ILO OZONE APN
m
cntrct urhe project(Sec.7044,Business and Professions Code:)The Contractors
License Law does not apply manownerof,imps y whobuitcs or improves thereon.and PERMIT ISSUANCE
who contracts forsuch projects with acornracmr(s)licensed moment o the Contractors gLTER-DRAIN&VIiNT-
LicenseLaw. WATER EA) FEE SUMMARY
❑ 1 am exempt under See. ,B&P C for this ream° BACK FLOW PROTECT.DEVICE OUTSIDE FEES
ANITARY Yry
Owner Date DRAINS-FLOOR,ROOF.AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby and that 1 have a certiftcale ofconsrnt m selGinsure,or a ceniftcate of RECEIPT 9
Wers'Compnmiionlnsumnceoracenifedc ythermf(Sec.3g00.Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
covers Piney#Il cryty ylep ypdcr rh o»TIN it `OO GAS-EA.SYSTEM.I INCA OUTLETS RECEIPT#
YJ 1l' rte]\TIN 1 BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby with
he city
Cenified copy is fled with theory mspenion division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed if Ne permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT.
or less.) ENERGY FEE
I sandy that in rhe Informmce afthe work for which this .it is issued,Ishan WATER HEATER W/VENTIELECR
not employ any person in any manner so ss to become subject to the Workers' PAID
z Compensatioulawsof Calif.mia. Dam WATER SYSTEMICREATING
Applicant Date Receipt#
OD NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT,rTOTAL:
� hccnme subject to the Worker'x Compensation provisions of the Labor Code,you must
� > torthwl th comply with such provisions or this ennit shall be deemed revoked. BUILDING FEE
LSl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that is a construction leading agency for the pMorrtance of
U O the work for which this permit is issued(Sec.309),Civ.C.) TOTAL: ELECTRIC IEE
Lender,name
O U 1<ndeh Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and state that the above information is
IL <rarest.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
L. pJ building construction,and hereby authonze represematives ofthis city m enter upon the
U z uhowe-mentioned property for inspection proposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liubilitiea,judgments.costs and expenses whichmay in any way aveme agairut said City AIR HANDLING UNIT(TO I0,003 CFM)
aqucnce.fthegraming ofihi 't.
'U AIR HANDLING UNIT(OVER I O,00M CFM)
Si to rent ApplicmVContmetor ate EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DI OSUR HEATING UNIT(TO 100,tKI0 BTU) // M Doc Receipt p
Will rhe applicam or fuwrc huilding occupant store or handle hazardous material �J
as refined by Me Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cute,Section 25532(0)]
❑yes ❑No VENT RATION FAN(SINGLE RF.SID)
Will the applicantmafuwrc defined
acceptedause Arco Air ordeviceswhichemit
BOILER-COMP LIHP OR 100,000 BTU) ISSUANCE DATE
humundr• Boom'us air contaminants as defncd by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) '
Distrim]
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hmarduus materials rcqum mems under Chapter fi 95 of the 0o T 7
it tiro building
lthdo&Safety Code,have
a te 15505,2x533 and responsibility
I understand chat rl 819g�
itof d.equir menta currently have a must
le, that prior my responsibility!e notify the n
...Pon of the requirements which man he met prior to issuance of o Certificate of
occupancy. Lr Lk-.�,a`r.
Owner or authottzed agent Date TOTAL: q3—00 ISSUED BY.\J
OFFICE