26832 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO 11 IIAI G-IiLEC'1'RICAL . PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL V V J
BUILDING DIVISION BUILDING PROTECT'IDEN"I'IPIGATION 26832
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31RLDIN11GADDRFSS: r•� SANITARY NO. APPLICATION SUBMITTAL DATE
L16. % C AAtJA— (1LUr1, UNITM LOT
OW ERS NAMI?: ' HO : ACfORBN1Mli: 1 LIC NO:
11:��4 vLZA XJC klYPNES
CO GY—bS"lS i SF-C-I•� Se>wt.'!c•- :Ta k7a3 NIC CONTROL»
` RCID'rliCI"UINHR: LIC NUi ADDRESS
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CONTACT: - PHONE: BUILDING PERMIT INFO
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1 �f Q"1'Y. ELECTRIC PERMIT NEP,
T-G(s �A a, ( 1"0I11, PERMITISSUANCE BLDG ELECT PLUMB MBCII
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL lOR ISCRIP11
WOO Thereby shooting,lum ticenseJ underpnwinionsnf Chnpta9(wmmencing whM1 ��
W00 gecticama0)of Divisinn3of the Business and Professions Code,antl my licenu is in PANELS Via)��y1 pF•^` L
yy�� Ldlforcanna effect<U License Class _a _ Contractor
UI'T0211(IAMPS -
F—DON�
m<y Date L CamraeD 201-IIgp AMPS
ZOtiys� ARCIIITF,CI'S DECLARATION OVER IOW AMPS SQ.E7.FLOOR ARRA $5Q,FM
OZ-0 I understand my plans shall be used as public records.
F y SIGNS ELECTRICAL
Licensed Profcsnional
wfd< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
�Ot� I lottery affirm that 1 am exempt from the Contractor's License Law for the
m34y following reason.(Section 9031.5,Business and Profusions Cade:Any city or countyM
TEP.METER OR PULE INST.
��5 which requires.Permit to consumer,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the Iicant for such rmiun Ble a ni ned statement POWF.RDEVICES
quires pp pe g
WC0.GpK that
rnislicensed pursuant eothe Provisions of the Corruption'sBasirestart
eLicenuesw(Chapter
m adOR. or had henexempthv 0ndthe Division Sof elle Business and.Any violation
SWIMMING POOL ELECTRIC VALUATION
F_Zw
or had 7031. byanovershoot ana the basfor a permitorlheallegedexrmptt to civil
of OUTLEFS-SWITCHIS-FIXTURES
1_Z0 Section7031.5than of any applicant subjars the applicant ecivil penalty of
t t more than role hamate)dollars($500). NF.W RESIDENTIAL ELF.CEN _SQ.FI'.
W 0 ❑ I,asownerofthepmpeny,ormyemployeeswirhwagesastheirsolecompensaeion, SrDORMSTYPE CONSTRUCTION
will do the work,and the structure Isnot intended proffered fersale(Sm.70,14,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
propertywhabuildsor improves thercon,andwhadues such workhimselfar throughhis
employeea,prmvidal rharsuch lmprnvemenrsare not intended nrofferall'orsale.If, OCC.GROUP RBS.UNITS
however,rhe building orimprovement is sold withinoneyeerofmmpletion,elm owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
suite).
❑ I,as owner ofthe property,umexclusively contracting with licensed contracmrvo QTY. PLUMBING 'RMrr FEE FLOODZONE AI'N
Lmstmce the project(Sec.7044,Baainess and Professions Code:)'Me Comonans
icenu Lnw does nor apply roan ownerofpmperry whobuildaorimpmves thereon,and PERMIT ISSUANCE
who conuuctsformch projects with a contractors)licensed pursuant n the Cnnerazu'r ALTP.R AIN&VENT- AT FA)
License Law. ( FCR SUMMARY
❑ I antexempt ander See. ,B&P C for this main pROT CB OUI;IDHMFS
SANITARY Y N
Owner - Dau RECEIPTa
-FLOOR, OOF,AR/.GOND.
WORKMAN COMPENSATION DECLARATIO - ISSCIIOOLTAX YN
49❑ lhemby affirm that l have aceof,cete of conunIt If re,macertifture ofRF;CEIPTtl
TUR' I'Ii 'RAP
Wnrker%Compensatipn lrnumnce orucenifieJ copy there Sec.3A00.Lab CJ which TANK FEE YN
covers nil cntpinyri a ander this permit. RECEIPT g
GAS-IiA. 'Y6TE INC 40UTLfiTS
Polity g BUILDING DIVISION FEES
Company G - A.SY M OVER (EA)
PLANCHECK FEE
❑ c lified entry is hereby famished.
Certified copy is fled with the city inspection division. FAS' DUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORK S' G SE TRAP SOILS FEE COMPENSATION INSURANCE
(This section need nae be completed if We permit is fornnehund dollms($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
in,less)
I certify0wt in the perfmntanceofthe work for which this perm'ui 'nvurd,leh WAT17R BEATER W/VENT'/ELECfR
nae employ any person in any manner sn ss to breome subject to a We Is' PAID
Compensationlywsof Califca ia. Dae WATIiR SYSTEMTREATING Date Receipt
OO NOTICE.TO APPLICANT:IL after making this Certxempon,you sou
Certificate of Exemption. NEW RESIDENTIAL PLMB. SQ.ET.
Z TOTAL:
M1aznmesubject nthe Worker's Compensation provisions of the LnMa Cale,you must
ai > forthwith comply with such provisions orthis prnmie shallh decimal revoked. BUILDING 113E
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm that them is a construction leading agency for the performance of -
the wink for wlanh this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC HE
Lender's Name
FEE F Iona Adana: QTY. MECHANICAL PERMIT' FEPLUMBING FEE
IeL
U eAfy that I have in-ad this Implicmron arta sem t Ne oMva inl'pmmtion Is
.�' a tomer.(agree mcamply with sEcityred county ca and state laws relating to PERMIT ISSUANCE
MECfIANICAL FEET
ff...., buildiagconstrietionand he amhmze re mivesafthiscity,menterupathe- CONSTRUCTION TAX
C V
U z abavennenrionea yfo m cri ALTBRORADDTOMECIL
(Wc to save,inde oily d harmless the City of Cupertino against
linbili':,judgntcnts,cost n rap aa sh may in any way accrue against said City AIR10,000ANDLING UNIT(TO IO, I CFM)
nsultanceof Um ring f1b it.
pG AIR I IANDLING UNIT(OVER 10,01g)CI•M)
gig pplicam/Conemmor Q �lDa, - EXHAUST HOOD(WNUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I 0D,000 BTU) Date Receip,#
Will the applicant or fame building oce.lontalme or handle hmaranus material HEATING UNIT(OVER 100,(gO BTU) - TOTAL:
is defined by the Cupertino Health and Code,Chapter 9.12,and the Heand Safety'
G.Ie,Sccrion 23532(uyl
❑Yes Nn VENTILATION FAN(SINGLE RTSID)
BOILER-COMP OUP OR JDEO kq BTU) ISSUANCE DATE
Will theupplicaorfumre building occupant use equipmemordevices which emit �1
�hazerd..a mair contaminants as defined by the Be,Are.Air Quality Management BOILER-COMP(OVER JOEODO BTU) .410
District?
❑Yes >(No NEW RESIDTNTIAI.MECII. SQ.PI'.
1 have read the hazardous materials requirements under Chapter 6.95 of rhe (s/ ((��
CaliforniaaHealth&Sillier,Code,Sections 25505,25533 and 25534.1 understand that l+ y 94
if the building does not currently have natural,that it is my responsibility to notify the Ur J9
UV
occupant of file requirements which must lc met prior to issuance of a Certificate or - rCkIIN
Occupancy.
Owner fir aumariud agent Date ISSUED BY:
OFFICE