26624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU ILDING-ELECT RI AI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26624 n A
BUILDING PROJECT IDE N'I IFICATIIIN o 2 4
BUILDING ADDRESS: �� SANITARY NO. APPLICA'DON SU/BMyOTAL DATE
-0NIT# LOT �'-�7y
OW SNAME: PHONE: C NIRA 'OR'SNAME: LIC NO: sYJ (Z l
AL Q J NIC CONTROL
RCHITHC'1'7ENGINHHR: LIC NO: b It ESS: ❑
&A — v.
CONTACT: PHONE:
QTY.. ELhCIRIC eRMIT FEE BUILDING PERMIT INFO
BLDG ELECT P UMB "ell
PERMIT ISSUANCE 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL
Qo4z Iherebyaff,.that lam licensed underpmvisionsofChapanc)rcommencing with ION DESCRIPTION
Ia100 action 7")of Division 3 of the Business and Profession&Code,and my license is in PANELS
((-- fullforce and eifeyyr''
yyW
Qz Limns ;4C c ic.p 0 IIP TO 200 AMPS
yZ Ume''�BTT//��''.. Comramnr UP TO 0 AMPS
F-yZ ARCHITECTS DECLARATION SQ,1'f.MOOR AREA $/SQ.R'.
ZOy— [understand myplansshall barred.,public rands. OVER 1000 AMPS
Oz—o
y � SIGNS ELECTRICAL
ss Licensee rrofas:conal
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xdOaU 1 hereby affirm that 1 am exempt from the License Licee Law for the
W 31+•an following reason.(Secoun 7031.5,Business and Professions Code:Any city orcornty TEMP.METER OR POLE INST.
4J�; which regmircs a permit m conswn,alter,improve,demolish,or repair any structure
_ 9 ^e
Y� priomaits issuance,also requires the applicant fm such permit to
esigned statement POWER DEVICES r� I'i QV
Wp that he is licensed pursuant to the provisions of the Contracmrs Liceme Law(Chapter -
ayo 9(ormmcncingwith Secdon70yriaLivision 3 arrive Businessand Professions Code) SWIMMING POOL ELECTRIC ._,vps Ll 17)
xx..vl ,� LUA ION
or that he is exempt therefrom and the breis for the alleged exemption.Any violation of OUTLCfS-SWITCHES-FI%TURESI v I V
Z Q Section 7031.5 by any applicant for a permit subjects the applicant too civil penalty of
$G not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ. 71
Cm [II,asownerofrepRpety,armyemPioyewwilhwagesmtheirsolecompensmion, •T TYPE CONSTRUCT ION
ped, will do the work,and dushucture is not intended oroffered bristle(Sec.7044,Business
.it Professions Code:The Ci m actors License Law does not apply an an owner of
property who builds or improves thereon,and who does such work himselfor through his
on employees,provided thatsuch impnsumenume not intended oroffered forsale.If. OCC.GROUP RES.UNITS
however,the building ur improvement is sold within one yew ofeomp sham.thrown, TOTAL.:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owncrofthe property,um exclusively contracting with licensed contractors to QTY. - PLUMBING PERMIT RiE FLOOD ZONE APN
Lconstruct the project(Sec.70%4.Business and Professions Cole:)The Contmnur's PERMIT ISSUANCE
icense Lawdacsnot applytoaao vocrofproperry whobudds m impmvesthemon,and �-�
who contracts frsuch projects with aconvactor(s)licensed pursuer to the Contractor's
Liceme Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em eacmpt under Sec. B&P C for thio rcumm BACK ROW PROTECT.DEVICE T TUI
SANITARY YN
Owner Data RECHIPI'#
DRAINS-FLOOR,ROOP,AREA,GOND.
WORKMAN COMPP.NSATIONDECLARATION SCHOOLTAX YN
❑ Iherchy affirm rmlhave ecertificate of consent mself-insure,oracertificate of RECIiII'T#
Workers Compensation lnwrance oreceniRd copy thereof(SaJA00.labCJ which FlXTURPS-PCR TRAP PARK FEE YN
covers all employee's under this t. REM Intr
P y Itertnv GAS-CA.SYSTfiM-I INC.40I1TLf?TS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Centrist copy is filed with the city inspection division. GREASEBNDUSTRL WAS'Hi INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GRCASHTRAP SOILS FEE
COMPENSATION INSURANCE
(Tbissection need net bacompletrd ifthe Permit is forooe hundred dollars($10B SEWER-SANITARY-STORM EA.200FT. ENERGY FEE.
less.)
I certify that in they afornmnceofthe work for which this pnmit is issued,l shall WATER HEA'L'ER W/VRNT/ELECTR
nm employ any .on any manner so ns to become subject to the Workers PAID
Comrensutiou Lawsof Colifome. Data TER SYS ,MiTREATING Date Receipt#
O Z Applicant a.
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NP. R 61DENTIAL PLMIL. SQ.FT. TOTAL:
fq become subject o the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such previsions or this remit shall be deemed revoked. evn BUILDING PEE
LklSEISMIC PER
0.. Q CONSTRUCTION LENDING AGENCY
V z I hereby affirm thatthen is a concoction lending agency for the performunce of
ELECTRIC PEE
the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name Q FEE PLUMBING Mill F Lenders Address Q'TY, MECHANICALPERMIT'
U 1 certify that I have read this application and state that the above information is
comet. I agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICAL FEE
building construction,and hereby maroon representatives ofthis city to enter upon the CONSTRUCTION TAX
U z above-memionN property for inspection puryoses. ALTERORADDTOMECIi.
.. (We).gree te save,indemnify and kap handers the City of Cupertino against
liabilities,' tents,cams tend expenses ich may in any wayeccmeegmail said City AIR I JANGLING UNIT IT'010,000 CFM)
e ofr ting of mit.
AIR HANDLING UNIT(OVER 10.000 CFM)
gnmurc pPlicam/Camera r U EXHAUST HOOD(W/DOC17
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 100.0y)BTU) Date Receipt#
Will applicant aim Mu building Code,
Chapter 9.12,
hanand
dle the Health and Safety HEATING UNIT(OVER IDDOM BTU) TTA L:
id
as def net by the Cupertino Municipal Cafe,Chapter 9.12,end the Health unit Safety
Code,Section 25532(.)'? VENTILATION PAN(SINGLE RPSID)
❑Yes ❑No
W ill re upPlicunt rn morn&hui[ding oavrum me eyuirmem nr devices which emit
BOILER-COMP(3HP OR I(p,t)(111 BTU) ISSUANCE DATE
hazardous air contaminants as defind by the Bay Area Air Quality Management BOILER-COMP(OVER 1000010 BTU) }A VD
District? LW
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have reed the hourdous materials requirements under Chapter 6.95 of the •�uN 11994
Cnlifomiu IIw6h&Saf.Vode
C ,Sections 25505,25533 end 25534. I undcrmand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occ of the requirements which um m m he mprior issuance of a CeniEcate of GI I I Ur
Occupancy.
Owner or aulhorieed agent Data TOTAL: ISSUED BY:
OFFICE