26431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BU66ING.ME HANICI. relRmlrrvD.
BUILDING DIVISION APPLICATION/PERMIT PLUM ROJFcrEDEN IFI A 1
BUILDING PRf1.INCT IDENTIFICATION
BUILDING,ADDRESS: - SANITARY NO, APPLICATION SUHMI'ITAI.DATE
UNIT# LOT#
OWNERS NAME: PHONE: CIRACTORB NAME: LIC NO: s-�{.C7 NTC CONTROL#
I`•ARCHITEiCDENGINEER: LIC NO: ADD ESS - ^ _ 11 .
yek
CONTACT: PHONE: N/YFE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECI.ARATION APPLIANCES-RESIDENTIAL'
pLz Thereby uf0tm thud am licensed underprovisione apter9 romancing w' - IOIi UESCRI ION
RoF Section 70,M)of ffDivision 3 of the Business and Pates ns Cade, dory licmu PANELS
Q Z VVI License Class_ Li<.p as UP TO 200 AMPS
y Q a Date Contmmm 201-1000 AMPS
Z FOy RCIIITECTS DEC,A TI OVER 1000 AMPS SQ.PI'.FLOOR AREA, $ISQ.FT.
O Z_Q I understand my plans.hall be used as public aid..
y ly SIGNS ELECTRICAL
ady7,J Licensed Professional _
gaaa'6 OWNER-BUILDER DECIARATION SPECIAL CIRCUIT/MISC. �a un� {'^mss
Od V 1 hereby ofGrn that I me exempt from the Contractors License Law for the 0 V T� Y
3 0 y following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. 0
Ee�g whichraluim,nperminnconstructahe,,imp rove,demalish,iompanan,concturo POWER DEVICES LV
yu;!Ir2 prior m its issuance,also requires the applicant for such Permit to file a signed statement YY
< that he is licensed pumuan to the provisions offie Contmaor's license Use(Chaper SWIMMING POOL ELECTRIC
L ,CC) 9(codamnciog with Section of Division 3 ofthe Business and Professions Code) VVAAL A
W_1,VY or Nat he is exempt memfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES IG
> Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Gnot marc man Ove hundred Jnllars(ESOB).
❑ l,asowncroflhepropcny,m aryemployeeswith wages astheiramacompersuramn, NEW RISIDENTfAL EL1!(:T'R _SQ.FT. STOREST Pl!CONyS'NUCTION
d3� willdothe work,ontl the structure isnot amended oroffcrcd forsale(See.7W4,Business
end Professions Code:The Contractor's License I,aw does not apply to an owner of
property whnbuilJsorimproves thereon.and who Jtes sacb work hinsulfmnlwoghhia OCC.GROUP RES.UN11 s
employees building
or improvement
mp ou mentis vemema arc one intendedmpled m,meniscus,
however,thebuildingorimpmvementissoldwithinmbmIdminismic mthcawner- TOTAL:
builder will M1:rve the burden ml proving that he did nm buil)or improve for purpose of
sale.). QTY. ' PLUMBING PERMIT FEE FLOOD ZONE! APN
❑ I,as owncrof the propery,emexclusively, contracting with licensed contrecmrse
consumer the project(Sec.70W4,Business and Professions Code:)The Contractor's
License lrwdasnmapply to an ownero(propeny whobim
uildsor pmvesthereon,and PERMI'I'ISSUANCE
whocamracfs for such projects with acontranor(s)licensed pursuant came Contractor's
License Law. - ALTER-DRAIN&VPNT-WATER(CA) PEE SUMMARY
❑ 1 am escmpt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE 'TSIDE FEE
SANITARY Y N
Owner Date RECEIPTp
DRAINS-Il,fbR,R001;AREA,COND.
WORKMAN COMPENSATION ofoo DECLARATION SCHO0I.TAX Y N
I hereby❑ eN'Conpenmthatfbaveceoraccmeofco)pyth sf(,murt,oracenifiauteof FIXTURES-PER TRAP RECEIPT#
Wvers al Comloyce'ionlerthis ermit. fcA raspy thereof(Sec.38o0,Leb C.)whlcb - PARK PHIL Y N
covers 111 nnpinycc's under this permit GAS-1!A.SYSTEM-1 INC.4OUTLETS RECEIPT#
Polley# BUII.UING DIVISION Plil!S
Company GAS-EA.SYSTEM OVER 41EA) PI.ANCIIECK FELE
❑ Certified copy is hcrchy funaf had.'
❑ Certified copy is filed with me city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - SOILS FELE
COMPENSATION INSURANCE '
(77+i.,ainormadma be completed Brim permit is foronehundred Jollars($100) SEWER-SANITARY-S'TORM EA.200FL. ENERGY FEE
orless.)
I acetify that in the performance affirm work for which this partner is historic,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Campcnsmion Lawsof CeliB+mie. Date WATNRSYSTEMo RPATING Dote Receipt#
APPlicnm
OZZr C) NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,you should NEW RESIDENTIAL PLMB, SQ.PT. T'O'TAL:
F-' fn become suhj.t1.she Winona Compensation pm,i,i.na.ftha l.aMr Code,you most
t� 7 forthwith comply with such provisions or this permit shall be deemed invoked. BUILDING FEF.
CONS9'RUCfION LENDING AGENCY SEISMIC FELE
1 bmeby affirm that is o contraction lending agency for the performance of
V Q)•-t the work for which this permit is issued(See.3f197,Civ.C.) IOTAL: ELECTRIC PEE
F-' Ixndera Name PLUMBING IEE
Lender',Address QTY. MECHANICAL PERMIT FIiF:
U 1 acidly that 1 have mad this application and state that the above information ie MECHANICAL FEE
areel Iagre comply with all city and county ordinances end stale laws relating to PERMITISSUANCE
huildiagcmmt ction,andh bya thmize representatives ofthis city to enter upon the
U7 above-memi+ mJ... .y rin,acfion putpnse ALTERORADDTOMIiCII. CONS7Rl1C'f10N TAX
G (We) me m save,i demnify and keep exs me Ciry of Cupcetino egsi.fast
Imbilitics,jt lgmcut caa end expenses tubi any wayeurue against said Cify AIR HANDLING UNIq'(TO 10,000 CPM)
in conjoin ce oft ting o(mis panni.
AIR HANDLING UNIT(OVER 10,000 CPM)
Sign+ ppll mac r Dam -EXHAUS'P HOOD(W/DUCT)
PAID
HAZARDOUS MA occupant
DISCLOSURE
HEATING UNIT(TO 100,00)BTU) Data Receipt#
Will the the Caprant o.Mu buildingaCocacupemeerc or handle hHealth andcdous Safety HEATING UNIT(OVER 104000 BTU)
as defined by the Cupertino Municipal Cade,Chap¢i 9.12,and the Health and Safety TOTAL:
Code,Section 25532ho? VENTIT.ATION PAN(SINGLE RESID)
El Yes ❑No - . .
BOILER-COMP(3HP OR I S."BTU) ISSUAf UTE
Will the applicant orfulure building occupaNC
nt use rquipmemaNeviceswhiaM1 emit Yt'f ApMM IJ
harnNous air commandants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,800 BTU)
District] 1:1WjAY 261994
❑Yes No NEW RESIDENTIAL MECH.-SQ.14.
1 hav rend the hezunlous materials onimmnema antler Chapter 6.95 of rho
Cnif iu Health&Safety Cn la.Sections 25505,25533 road 25534. 1 understand that Fl/
if the building does not currently have a mason.that it is my responsibility tin ramify the CITY Ur kiurt
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or atuherized agent Data 'TOTAL: ISSUED BY:
OFFICE