26446 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO H [GOING-ELEL RICA]. PERMITNO
APPLICATION/PERMIT PING PROG-MhIDENTICAL
FICA 2'6 �1 �1 C
111111.DINfl DIVISION IIUILHING I'ROJE[:'I'IDh:NTIFICA'I,ION vLl Lao
.DING ADDRESS 11 /�•y� SANITARY NO. APPLICA I]O�N S/U`B�MITTAL DATE
je%Aq f I b � x UNIT LOT# _
O iRN NN Mfc k O (�fp.1NH:.� (� CO CT R'S LIC NO: N/C Cp'NTxB(ll.#♦
RCHI'JECf/FNGINIiHR: - `LIICNO: ADDRESS: ❑.
ONTACI': PHONE:
QT'Y. ELECTRIC PERMIT - PEE . BUILDING PERMIT INFO
I_ 31.1?CI' PLUMB MliCll
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL 1 I
OKZ - Thereby affirm that am licensed unJerprovisions at Chapter!)(commencing with J
f+100E Sce..... Wtp of Division Jof the Business and Prnl'eaxi.nx Code,and my license is in PANELS
KUIJ full force and effect.
1Q,Zod License Class Lic.N UP TO 200 AMPS
ar<d Data _ Conn.., - 201.1000 AMPS
ZOyRS ARCHITECT'S DECLARATION OVER IWO AMPS SQ.FT.FLOOR AREA S/SQ.T.
0Z'-n Iunoc,aanl my plans shell be anal as public records,
SEL L uI SIGNS ELECTRICAL
6y ; Licensed Professional I ® 8 .I
map,y.e'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
h 0O `V. I hereby affirm that 1 um exempt from he Committers License Law for the
W1 :tat following reason.(Section,9031.5,Biaonessand Pmfessi.ns Cale:Any ehyore.amy TEMP.METER OR POLE INET. r5 rt room II II ;�
k��I which requites a permit to consh.cl,a ter,improve,demolish,or repair any sanctum �\9/Yp P pU II_w
zn�7 primm irs:snnce,.1fo rey.ires lheapplicnt f.rs.ch pemtint file.aignedetammem POWER DEVICES
�K¢0 that he is licensed Furs...the sawkmns of the Contractors License Law(Chapter
m o 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC U I
.shat he is exempnherefmmand the basis f.r,heulleged exemption.Anyvidminn of -
L.'�a
Section
by any nppliwnl Toru pvrmir subjects the nppliwmmucivil parially nl' OUTLETS-SWI'I'CIIES-fIXT'URES'
C2d2 am marc than five hundred dollars(S5W). NIiW RESIDFMIAL ELF.CfR -SQ.Irf.
43=° [j1,asownemfthepmpeny,ormyemployreswith wagesesnc�irsnlecompertsminn, STORIES TYPECONSTRUCION
will do the worli the structure isnot intended proffered forsale(Sm.](44,Business
and Professions Cale:The Contractor's IJaose Law does not apply to an owner of
property who builds m!mpm,,,thereon,and won Jrws such work bimsel f or through his
empinycex,pmviJ<J that such impmvemem>ae nnlimendeJuruffercdfrrsale.
If. OCC GROUT' RES.UNITS
fowever,the building.,improvement is sold withiu n ,can.fcomplethn,meowner. .t
builder will have the hands.of proving that he did not build or improve for purpose of
sale.).
El Las.wnerofthe property,arnmel.slvely contracting with licensed contractors to QTY. PLUMBING PERMIT FEF: PLOOU'LONE AIN
construct the project Low.704Q Business and Professions CWc:)Tim Contractors
License Lew contestant apply to an menerofpmporty wh.builds orimpmves thereon,and PERMIT ISSUANCE y
whommmnsfm such projects with acaeractorts)licemad pursunuothe Conaacmrs se Law.
Lice ALTER-DRAIN&VENT-WATESUMM
R(EA) FF.F. ARY
❑
License
vat exempt under Sec. B&P C for this reason BACK FLOW PRO'I'ECI'.DEVICE UTSID: Ps-
. Y N
Owner Dam RECIiIPTp
DRAINS-Ff.00R.ROOF,ARPA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ers'Co acroanothat Insurance
ce or accateofcomemtosel!-rac.39 0,L.boraciaC.)whichficatoof FIXTURES-PER TRAP RECEIVE If
W.,kers'Comloyers nlmaumnceuraccni0ed copy mereof(Sec.7g00,Lab CJ which PARK PIiE- Y N
eolicy#lenipluyce's under this p.nnif GAS-HA.SYS'fliM-1 INCA OU'T'LETS kEIVISI p
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4 THAT PLANCIIIiCK FEE
❑ Cenifiedmpyishercbyfumished.
❑ Cerifiedcopy is filed with the city inspection division. GRIASHnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE'BAP SOILS FEE
COMPENSATION INSURANCE
rGiissectionneednolbecompletedifmepermirisforenehundmddollars(SIW) SBWER-SANI'T'ARY-STORM FA.20017. ENERGY TEE
.r less.)
Icentry to.,in the performanceof the work for which this permit is issued,I shall WATER HEATER WNEWIFLMR
am employ any person is any ma.a,,so as t. become subject m the WorkersPAID
Z Compen.xaliou Lawsof Califomia. Dale WATER SYSTL'M/IRFATING Dam ecei
Rpt#
Applicantz�z�-i � NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. T' rAL:
bernmesubjecr to the Worker's Compensation,provisions of the Labor Cale,you must
Fri
both,nit comply withsuch pawisiumormi,permit sbnll be deemed rev.ked. BU I LDING FEE
L1, CONSTRUCTION LENDING AGENCYSEISMIC FEE
z. 1 hereby affum tha them ix a consrmaion lending agency for the performance of
U O The work for which this permit is issued(Sec.309],Civ.C.) EL[CI'RIC FEE
1,
Name
1j. Lender',
MECHANICAL PERMIT FEE PLUMBING
LndI Address
U I eemry That 1 have read this application nn,state mat the above inramahn is
�" fist correct.Iagree to comply with ani cit and court ordinances and
and . ces d state laws adatin to PERMIT ISSUANCE MECl1AN1CAL FT:E
.Fy U) btildingeosrcrion, d hereby ammoreprmentativesof Nis city to enter upon he - CONSTRfICDON TAX
U ,Z alsave-menlipned property for inspection purposes. ACI'ER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
'bilities,judgmems,costxand expenus which mayinuny way eceruengainn saiJCiy AIR HANDLING UNIT(T010.000 CFM)
yuapcethegmnti ofshis permit.
5- AIR HANDLING UNIT(OVER 10.01p CFM)
Signature of Applicant/Conva¢for Dam EX HAUST 11001)(W/DUCT) PATO
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I00,00)BTU) Dom Receipt#
Will the the Cupnt or ertino uicre ipalCng deeupnupmm handle hanpdotns nearmod
ldSafety HEATING UNIT(OVER IW,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Ilwlm told Safety
Code,Section 25532(1)? V, TILA'f1ONFAN(SINGLERFSID) -
❑Yes ❑No hAPI
BOILER-COMP(JIIPOR IW,(XNI BTU) IwySySU CE ATE
Will the applicant future building assonant use equipment ordevices whichemir - IS ll p
hazardous air c0meminatts as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 10(1,000 RTU) A
District? BOILER
Qj
11 Yea, ❑No NEW RESIDENTIAL MECH. SQ.17. I+q / �n/S� .
1 have read the hazardous materials requirements under Chapter 6.95 of the 7.`94
California Health A,Safely Code,Sections 25505,25533 and 25574. I understand that 'I
if r n,scon oing t res wt cu ons which
....
tenant,that itis,, responsihility to nmify the h L(//••��
cupnnt.f the rcyulrcnteme whish nmsl be mel prior m issuance of v Certificate of
Occupancy.
Owner nr authorized.gem Date TOTAL: ISSUED BY:
OFFICE