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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL UING-F.1?L'rRICAL
BUILDING mERTI APPLICATION/PERMIT PLUMB NC3-MECHANICAL
BUILDING PROJECT' IUENI'IF'ICATION
PERMIT NO.
26674
IIUILUINGr woDRE155:�
SANITARY NO.
APPLICATION SUBMITTAL DATE
1 O W •�+ Sr�Y� UNIT# LOT#
.�NLA
OWNERS NAME: PHONE:
`fh�Ael IEC Cof1 R �t95- 3491
CONTRACTOR'SNAMLIC NO:
NIC
❑
CONTROL#
ARCHICT/ENGINF.ER: LIC NO
ADDRESS: -
'c'ON'T�ACT: A PHONE:
c' y.���
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELLE PLUMB MECH
Ir�JITCy_
gbm
W�F'a.� V" py 9
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herchynff n that l am heensedunder provisionsuf Chapter 9(commencing with
APPLIANCES R NT L
JOB DESCRIPTION
Section 7000) of Division 3 of the Business and Porfesaimot Code, and in, license is in
full force and effect.
PAN
LlcerscnLic.g
'O MP
Date Contractor
201 r A C
ARCHLrECTS DECLARATION
1 undcmmnd my plure shall be axed us public raords,
_ SQa4.FLOOR AREA 8/SQ. FT.
Q
V 1(00 PS
c u I o A Inom/
SKINS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I
SPECIAL CIRCUILMISC. 0` 1 L
I hereby affirm that 1 am exempt form the Contractors License Law for the
TEMP. METER OR IDLE INST
following reason, (Section 7031.5, Business and Professions Code: Any city or county
which .,mora a perrom m construct, Morn, improve, demolish, m «pair any Nraeame
Primus its issuance, aka requires the applicant fortich permit to ?ilea sigM
nUam
tsent
-
POWERDEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9(commencing with Section 7000) of Division 3 of the Business and Porfeasions Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
SWIMMING POOL ELECTRIC
w VALUATION
O
OUTLETS - SWITCHES - FIXTURES
oat more than than five hundred dollars WOOL.
❑ I,mowner.f Nepropery.ormyemployeeswlthwagcsmtheirsolecompensution,
NEW RESIDENTIAL ELECIR S Q.
Q
�!
STORIES
I'YPH CONSTRUCTION
willdothework,andthestmcwre is not imendedoroffered forsale(Sec. 70,14, Business
and Professions Code: The Ciamrectora License Law aces nm apply toe son owner of
property whobuildhaimpTaves Nereon,and whodoeswelt.ork himselfa,thrnughhiz
mm
soremployces, providedthat such improvecnmnot intendedorofcrodforsale.If,
OCC. GROUP
RES. NITS
TOTAL:
however, the building orimprovemcnt is sold within one yearof completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las ownerofthe propeny,emexdazivelyconracting wiN licensed cantrecmrs to
QTY.' PLUMBING PERMIT FEE
FLOOD ZONE
APN
ronshact the project (Sec. 7044. Business and Professions Code:) The Contractors
License Law docs not apply to an ownerofpropcny whobuildsor improves dtercon,and
PERMIT ISSUANCE
whoconimaforsuchpmjx0withuconuactm(s)Iicensedpurzuaitothe Contracmr'a
License Low.
ALTER - DRAIN&VENT - WATER (PA)
FEC SUMMARY
❑ 1 am exempt under Sec. , B & P C for Nis reason
BACKFLOW PROTECT. DEVICE
IIT. ID ES
SANITARY YN
RECEIPT'#
Owner Dam
DRAINS - FLOOR, ROOF. ARCA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN_
'❑ IM1crtby ef0rmthasJ heveacenificem of consent to self-insom,mecenificate of
Workers' Compeamtian Insurance or accafied copy thererf(Sec. 3800, Lah CJ which
covers all employee's under this permit.
Policy #
RECEIPT#
PICTURES - PER TRAP
PARK FEC Y N
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION Fro I
Company
GAS - EA. SYSTEM -OVER 4 (IIA)
PLANCHECK FEE
❑ CeniftMcopYnshersbyfumishd.
GRFASFJINDUSTRL WASTE. INTERCEPTOR
GRADING FEE
❑ Ccnifid copy is filed wiN Ne city inspection division.
CERTIFICATE OF EXEMPIION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FC
ENERGY FEB
(Tnis section acdnotbecompletedifthepcor0itis foronehundreddollars(S100)
or less.)
WATER HEATER WIVEN'JELECR
I certify that in the Performance of the work for which Nis Permit is issued.I shall
not employ any perm. in any manner ao az to become Object m the Workers'
PAID
Compensatioul.swsof California. Date
WATER SYSTENUTREATING
Dam Receipt#
Applicant
NOTICE TO APPLICANT'. If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
becrnne subjecuo Ne Worker's Compensation Provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEC
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there iso emiumctiom lending agency for the Performance M
the work for which this permit is issued (Sec. 3097. Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Address
1 certify that 1 have read this application and state that the above information is
correct. INina, to comply with all city and coumt,.rJouwas and state laws relating to
PERMITISSUANCC
MECHANICAL FEE
buddingcausumcdon, and hereby authorim representatives ofthis city to enter upon the
above-mentioned pony for"Ok"n.an purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) a indemnify and keep harmless the City of Cupertino against
liabilities,ju costs and expenses which may in any wayaceme again Oid Ciy
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER IO.f00 CFM)
in cone is agora
. /
EXIIAUST IIOOD(W?DUCTI
PAID
ria o pplicanVContmnor a
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt If
HEATING UNIT (OVER 100,000 BTU)
TOTAL.
Will the applicant or future building occupOt store in handle hsnardous mmerial
as defined by the Cupertino Municipd Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RFSID)
Code, Section 25532(a)7
❑ Yes ❑ No
ISSUANCE DATE
Will theapplicamorfaturebuildingcountrnt use equipmentordeviceawhichemft
BOILER- COMP QHP OR 100,000 BTU)
BOILER - COMP(OVER 100.000 BTU)
App hasudous air emoseni ants as defined by the Bay Area Air Quality Management
■District?
NEW RESIDENTIAL MECH.-SQ, FT.
13 Yes 0 N
r
P % A I D
I have read the harardois romenals requimmems under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, M533 and 25534. 1 understand that
if the building does not mmantly have a tensa. Nat it is my responsibility m notify Ne
JUL n 7
FI
9
Occupant of Ne requirements which must be met prior m issuance of a Cenificate of
A
Oecupanay.
city
ISSUED BY: �A 15(ff(sJ
Owner or manoriud agent Data
TOTAL:
OFFICE