26444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRI AI. PERMI'1'NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26444
BUILDING PROJECT IDEN'TIFICAT'ION
BUILT AUDRF'_SS.020 IF '5ANI'fARY NO. API'LICATIONSUBMII'I'ALDATF.
LOT'q rA
.RSAME' � t 6G: / fOMIRA.ww0.��S NAMIE: LTC NO:..
NPC U)NT'ROLM
• AV A
RCIIITICf/TN .IC
GINEER: INO: AD SPIV
CONTACT: _ PHONE: , BUILDING PERMIT INFO
QTY, F,LIiCI'RIC PERMIT Pf?E
`74LDG PLUMB MECH
PERMIT ISSUANCE
LICENSLD COME RACTOR'S DECLARATION APPLIANCES-RESIDMNUAL
❑zz Ihere ...niturder,ravisisonsiffariI h,mrmendng with JOB DESCRIF1TON
;tJ00 Scction 7001 Division 3 of the Business and Pa.fnsmas Code,and my Beets is in PANELS
tY
full(urcc and cff '�^ 11P TO 20(1 AMPS
6z, Lice 'Iass_ I.i.p_ti�
rFn�d reCon[rac.r 301-I0W AMPS
H ARCIIITIiCTS UECLARA PION OVER 1000 AMPS SQ.Ff.FLOOR AREA g/SQ.IT.
OZ
O I 1 understand my plans shall I be used is public records.
HE SIGNS ELECTRICAL I r R
Q E,'� LicenseA l'ru(cssional
OWNIiR-tlUILDER DIiC Contractor's
SPECIAL CIRCUIT/MISC.
yyOIF I hereby affirm that 1 aa exempt from tM1e Commemr's License Low for the
tXil3aGtn fullowingreason.(Section 7031.5,Business and i'rolessiona Code:Any city.,county TEMP.ME I'ER OR POLE INS r.
rF J which requires a permit to construct,et,alter,improve,demolish,or repany swmurc
ed ,7 priorto its issuance.also requires 0m applicant forsuch permit m file a signed statement POWER DIiVIC175
�K�OO that he is licensed pursuant to the provisions of the Contractors license Law(Chapter
dxdo�' ----
9(commenting with Section 7")of Division 3 of Business and Profession;Code) SWIMMING POOL ELECT' ^— VALUATE116 a
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTI TTS-SWU'CIIliS-PIXTURLS Q�
Za Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). NEW RESIDENTIAL ELLCfIt
ta p ❑ I,asownerofthepropeny,era o,ancandalmthercd f sale
lco Sabi. Q t STORIES TYITCONSTRUCION
y will dmbcwmk,Code:
The ContisnoraLic Ise Law do s not apply t sm Business
and property
whlons Cele:The Contractor License Law docs not apply m an owner of
propedywyees,prsmi.provesth im,mo.dwhndoeasuch wmk himsdrm lhmughhis OCC.GROUP RES.UNITS
own employees,provided thauuch impmvementaart oat immnded proffered for sale.If,
however,the bulldiag or improvement is sold within one yeurofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve fur purpose of
sale.).
❑ I,asowncrofihepmpeny,ameaclusivelyconwactingwiNliceteedc.ntracmrsm QTY. PLUMBING PERMIT FEE 17LOOD ZONE. APN
onswet the project(Sec.7(44,Business and Professions Craft:) Me C.nbaemrs PERMIT ISSUANCE
License Law docs not apply to an owner of propcny who builds or improves thereon,and III,I
License
whawsforsuch pmjectawiW aconvaaor(s)IicenseJpursunnunthe Commemrr ALTER-DRAIN&VENT-WATER ERA) FEE SUMMARY
se Law.
❑nI am exempt under Sec. ,B A P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE pEES
SANITARY Y N
Owner Dam RECEIITq
DRAINS-FLOOR.ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATIONSCIIOOLTAX YN
❑ Thereby affirm lhm lhaveaccnificum of mnummulf-Insure.or ecetificam of FlXTLRFS-PER TRAP RP IPTN
Workers'Compensation Insurance ora certified copy thereof(Sce.3800,Lab CJ which - - - PARK FEE Y N
covers all employee's under this permit. GAS-FA.SYSTlih1-1 INC.4 OUTLETS I Pf p
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(PA) PLANCI IECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREAS INDUSTRI.WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(Thisaeclum eednotbecompleedifthe permilis fo mahuadreddallaropli(t) SEWER-SANITARY-STORM EA.201 ENERGY FETE
or I.I
I certify that in the performance ofthe work for whichthispe.In is issued,Ishall WATER HEATER W/VENT/ELECTR
Out employ any person in any manner so `oCn the Workers PAID
satins l,60 f Califomi I WATER SYSTEMl1'RP.ATING Data ReI Of
Q zplicum li4 o V �-
Z NOTICE T(JAPPLICANT:If,after.0RTV i7ertiticate of F.xemptimr,ma should NEW RESIDENTIAL PLMB. SQ.Fr. 'DOTAL:
F' I Iscro.esubject to the Workers Compensation provisions ofthe Labor Code,you most
� ; forthwith comply withsach provisions or this permit shall be reamed revoked. BBELONG FEE �
W QSEISMIC Fill!
LENDING AGENCY
U O I hereby which
this
is a construction 397.lending s agency for @c performance of q'o ELECTRIC FIiE
ten work for which This pemsit is issued(Seco)097,Civ.C.) l
Lei Lender's Name
Lender's Address Q'I'Y. MECHANICAL PERMIT FEE PLUMBING FEE
L)
I certify that 1 have real this epPlicmi.n end stau that the above informetinn is
coovt. I;grec In comply with all city and county ordinances and stme laws renfla,m PERMIT ISSUANCE MECHANICAL TIE
f--' building construction.and hereby amhoife represnlatives adds,city to enter upon the CONSTRUCTION TAX
C) Z uhove-actioned property for inspeation purposes. ALTER OR ADD TO MGCH.
(We)agree to save,indemnify and keep humless the City of Cupertino against
Iiubilitics,juJgmems,costs and exrensex Each mayin any any accrue against said City AMHANDLINGUNIT(T010,000CPM)
it,cI the gmn' his
aj' AIR HANDLING UNIT(OVER 10,0(X1 CFM)
Si crura of Applican4ComrnctorData PXIIAUS'f HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO PER"BTU) Dale Receipt#
Will the applicant or future building occupant store or handle hazardous mated.( HEATING UNIT(OVER 100,000[ITU) TOTAL:
as defined by the Caren an Municipal Cattle.Chapter 9.12,and the Ilealth and Safety
Code,Section 23532(n)3
11 Yes ❑No VENTILATION FAN(SINGLE RESIDE
Will the applicant nrfmurcbuildingoccupant useequipmrnmrdeviceswhich emit
BOILER-COMP(JEEP OR IM,W BTU) ISSUANCE DATE
hazardous sir contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID
�DlsniCl'I _ .
❑Yen ❑No NEW RESIDENTIAL MECH. SQ.Irl'.
I have read the hazardous materials ruquUcments under Charter 6.95 of the199q
California Ilealth k Safety Codc,Sections 25505.25533 and 25534. 1 undershoot
if the bni(ding does not carnally have a terenl,that h is my resp troibilly m notify the C/T.
Ocupant of the requircme is which must I met prim to issuance of s Certificate of f(( (J
ccupancy.
Owner or amhoriu)ageat - Date TOTAL: ISSUED BY:
OFFICE.
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