26073 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
❑ICBING-MECHA I PERMITNO, O
CITY OF CUPESIO NO APPLICATION/PERMIT PING,PRNG-MRCIIANICAL
BUILDING DIVISION IIIIILDIN'1:PROJF.LT IIIENI'IFIL'ATION
B73
UILDING+ADDR,ES�S::g{���1 SANITARY NO, APPLICATIONSUBMITALDATE
2.2 # LOT»
-OWNERS NAME: PHONE: CO C OJfS NAME: LICN :�` NIC CONTROLp
0' IleOefs 11 D �4 O
NC"T, FIENGINBIeR: LIC NO: D%5s: dJaK f ^� ).511
CWNTACT: PHONE: '`&n.k° a "^ '•f y -L;J, ::BUILDING PERMIT INFO
QTY.'I a t j 5 BLECTR C PERMIT y k FEE -[
d"^ i - - LD G ELECT P��UM/g MI CH
PERMIT ISSUANCE �� 1/Y
LICENSED CONTRACTOR'S DECLChapdaN APPLIANCES RESIDENTIAL
rCp11p1I-1
P p00 Ih7000).fmitha0 am licensedic..a rovisiesofns CWr9(it my licamg with
1 0.100 Section]000)of Division 3of 0e Business end Rofessionx Code,entl mylicense is in PANELS
full force and effect. UP TO 200 AMPS
1:core Class Lie.M
HQL me ConIncI 201-1000 AMPS
ZOw, ta
ARCHITECTS DECLARATION OVER IBM AMPS 5Q. `pI Y{,l�p IIIA I{1 SISQ.Ff.
O Z—O I undersnd my plans shall be used as public words. t { \� L�
co W SIGNS ELECTRICAL
<— Limi ud Professional r � VT
_
5gtY OWNER-BUILDER DECLARATION SPECIAL
.CIRCUrrMSC. t ` 11 u �
nwu I hereby affirm that I am exempt from the Combat License Law for the
X e'. following reason.(Section 9031.5,Business and Professions Cale:Any city or county TEM.METER OR POLE MST, 3
Eee2'1�Oy which requires a permit m construct, m
tt,alter,improve,deolish or repair any structure TE
C�}� prior m its issuance,ulan requiresthe applicant forsuch permit to file a signed statement POWER DEVICES
Iv
C K a 0 that he is lionord pursuant to the provisions of the Contractor's License Law(aripmr
aio 9(comm000
encing with Section] )of Division J ofthe Business and Professions Cede) SWIMMING POOL ELECTRIC 76
VALIJs>R'JPy4
C�7
�^-oe
or he is exempt Mammon and the basis for the alleged exemption.Any violation of
Y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES FIXTURES VCl
p
not more than five hundred dollars(5500). NEW RFSIDRNTIAL ELGCTR _SQ.PI'. STORIES TYPE CONSTNUCI'ION
w m ❑ Lasow,k,.cd thestmty,ormycmpinyecawithered f nsthcirsolccompensation,
will dothnwons Code:
The Comisent is License
Law
snote(Sly to
Business
and Professions Code:The Conrracmra License Law does not apply m en owner of
pmperty who builds or improves Merton,and who does such work himselfoahrough his OCC.GROUP RFS.UNITS
room employees,providedthat such improvements a arma imendaloroffeiedforsale.If,
V it
however.Ne budiingorimpmvcment is sold withinane yearofcompledon,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
a 'salo . OD—ZONE APN
Iasowmrolthcproperty,smoxcl mively contracting licensed conduct t QY PLUMBING P ' ?F,El
;-
conswet the project(Sec.7014,Business and Professions Cede:)The Contremor's
License Law does not applyto anownerofpropcny shobuildi or imm
pres thereonand PERMIT ISSUANCE
who contacts forsuch projects wideacommetor(s)licensed pursuant o the Connector's ALTER-DRAIN&VENT-WATER(EAl FEESUMMARY
Literate Law. OUI
[31 run exempt under Su. ,B&P C for Mia recon BACK FLOW PROTECT.DEVTC13 .IDL FS
SANITARY Y—N
owner Date RECEI FI'k
GRAINS-I1.00R,ROOF,ARRA.COND.
WORKMAN COMPENSATION DECLARATION SCH(II)1.TAX YN_
❑ IAereby affirm that l haveacenifieete m,muent mael(-insure,oracufificate of FIXTURES.PER TRAP RECEIPI'K
Workers'Compensation Insurance er acerifmd copy thereof(See.Jg00,Lab CJ which ' PARK hEE Y "N
covers all employee's under,this pronna. GAS-EA.SYSTEM I INC.4 OUTLETS RfCE1PT Y
Policy p BUILDING DIVISION FE
Co Y GAS-EA.SYSTEM OVER 4 HzAd PLANCHECK FEE
Certified copy is hereby fumiahcd.
Certified copy is filed with the city inspection division. GREASMNDUS'TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPSOILS FEE
COMPENSATION INSURANCE
(This auction need not be completed ifthe permit is foram hundred dollars(SIM) SEWER-SANITARY-STORM EA.2MFT. ENERGY FRE
or less.
I artify that in the perform.of the work for which thispemn is issued,l ahall WATER HEATER WIVENTIELECIR
not employ any person in any manner ao as ten become subject in Ne Workers' PAID
Compensation Laws of Califosnia. Dam WATER SYSI'RM(TREATING Dam Receipt k
ZApplicant
7� O NOTICE TO APPLICANT:IL after making this Catificiteof Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
[-: I,, become subject to the Workers Compenution provisions ofthe Labor Cade,you must
tY 7 forthwith comply with such provisions or his pnmit shall l:e domed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEI S M I C FEE
VZ I hereby affirm thatthem is a construction lending agency for Ne perfomtence of G FTE
O the work for which this permit is issued(Sec.3097.Civ.C.) LLLCENI
Lenders Name ?: PLUMBING FEB
Lenders Address QTY:y_ MF,CHANICfAL-PERMIT
V 1 certify that 1 have mad this application and soon that Ne above information is - MECHANICAL FEE
"J correct I agree to comply with all city and county ordinances and some laws relating to PERMIT ISSUANCE.
building concoction,and hereby authmire repreaenutivesofthiscity toenterupon Ne - CONSTRUC IONTAX
(� shove-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmcnu,costs and exponcs which may to any wayaccmcagainst said City AIR HANDLI NO UN IT(TO I OfflO CFM)
^equenc the g'antin his permit.
AIR HANDLING UNIT(OVER 10,"CPM)
St reof plicumcmdorator Date EXIIAUSTHOOD(W/DUCO PAID
HAZARDO S MATERIALS DISCLOSURR HEATING UNIT(TO 100.000 BTU) Date Rettiptp
Will the applicant or future building occupant stare or handle hrrackms material HEATING UNIT(OVER i00.000 III U)
us defined by the Cliicnim Municipal Cosle,Chapter 9.12,and the Ileahh and Safety
Cede,Section 25532(a)? VENI'IfATION PAN(SINGLE RRSID)
❑Year ❑No
ISSUANCE DATE
Will the applicant or future building occupant use equipment ordevices which emit BOILER COMP(JHPOR 100,000 BTU)
hazardnhs air co dsommants as defined by Ne Bay Ars Air Quality Management BOILER.COMP(OVER 100.000 BTU) P A D
District?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. AR ._
1 have read the Indications materials requirements under Chapter 6.95 of the (I . 994
California Health&Safety Cade.Sections 25505,25533 end 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the ser I+Ur
occupant of the requirements which..in be at prim to mucame of a Certificate of M I I
Occupancy.
Owner or amhorirzd agent Data TOTAL: ISSUED BY: