26452 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD; -ELE.fRI AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMB Cr]DEANICAL 26452
Iy /� �^+ BUILDING PRO1F.Cf IDENTINICAT'ION
Ha23O�S MOUS �� SANITARY NO. APPWCATONSUHM 'ALUATE
UNIT# LOTH �r<y
OWW:NS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC COONTR06B
�
A HCH I IF..CI'IEN01NHItW LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PEr BUILDING PERMIT INFO
RMIT IEE
NLDG E�LEJC�T PLUMB ME 11
PERMIT ISSUANCE �. 'ISL,
issite
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL •�� JOB GDESCRII'f10N
q C'Z lherthyafrimICthat NSE licensed under visDECL RATIr9(cnmmencing with PTION
IA00Section 7000)of Division of Ne Business and Professions Cade,and my license is in PANELS
5dE full force and exe �• V •�
yGG'yzw License a Lie.#tris¢ IIP T0200AMP5
6y Date Contraztm 2(11-IIA'IH AMPS
70rn= ARCHf1ECT5 DECLARATION SQ.PT.FLOOR AREA f/SQ.Fri.
OZ I understand my plums shall be used as public mord,. OVER 1000 AMPS
SIGNS ELECTRICAL
VLicensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
nC61 hereby affirer Nat 1 am exempt form the Communes License Low fns the
.;i;u.a following reason.(Section 7031.5,Businessand Prefco iov Colc:Any city orcounty TEMP.METER ON POLE INST.
4 O;rt
which esPum a permit to construct.alter,improve,demolish,or repair any structure
,eprior oits issuance,also requires the applicant for such Permittofile asignMW
statement POWER DEVICES
tt <0 that he is licensed pursuant in the provisions of the Contractors License Law(Chapter
lyoe' 4 ememermin,with Seninn 70110)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iWM, or that he is exempt herefornt and Ne basis far the alleged exemption.Any violation of
zG Section 7031.5 by any applicant for a permit subjects the applicanuaacivil penalty of OUTLETS-SWITCHES-FIXTURES
G
at marc than rive hundred dollen($50)).
❑ l,asowncr0fthepmprty,ormyempineeswithwagesastheirsolecompenxation, NCW RI51DGNT1A.ELECTR S .PT. S'TORIES
TYPE CONSTRUCTION
y22 willdothe work,anUhe structurekind intendumoffered fmrrals(See 7044.Business
and Professions Cale:The Contmcusrs License Law Arcs nm apply to an owner of
property whobuildsorimprovesthercon,andwhoduessuch work himselfonhrough his OCC.GROUP RES.UNITS
ownemployees.provided that such improvements nmnot immndedorofferedfarue,If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of porving that he did not build or improve for purpose of
sale.)' QTY. PLUMBING PERMIT FEE ROOD ZONE APN
❑ I,asownerolthe porperry,emexclusivelycamrvcting with licensed rnnhacmrsto
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License law dues not apply to an owner ofprnpeny who builds oridepor
as thereon,..] PCRMI'T ISSUANCE
who commem forsuch projects with ammmnetor(s)licensed par..-'mhe ComorcloI ALTER License Law. A) FEE SUMMARY
❑ I ten exempt under Sea B&I'C for this msan BACK ROW PROTECT.DEVICE SI EFF.S
SANITARY Y -
N-Owner Dom RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-BOOR,ROOF,AREA.COND. SCHOOL TAX YN
❑ lh<rehy ufrirm Nntlhevcoceniriceta of conrennoselGinsure,m ittenificateof Fl%TUNVS-PER TRAP PARK
#
WmkeriCmmpensatiun lnsumrme aroeenifiedcopy thereof(Sec.J800,LebCJwhich PARK FEE Y N
cosmall cm IyyFc'syndyatl�g�trpjl. RECENT#
BUILDING DCVI ION ••F:S
Policy N
((�(dLs�s( GAS-F.A.SYSTEM-I INCA OUTLETS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FER �a
eenifled copy is hereby famished.
mified copy is fled with the city inspect ion Ji ims GRFAS'VINDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFlCATEOFEXEMPTIO ROM ORKERS' GRHASRTRAP SOILS FEE
COMPENSATION, SURANC
(Thisscctionnad not be complmcd'- epermBistro. hundruddollon($100) SEWER-SANITARY-STORM EA.20(1 ENERGY FEE
or leas.)
I certify that in the perform ofihe work for which Nis it is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in manner so as to became sub t to the WorkersPAID
Compensation laws of omia. Dom WATER SYSTBM/1'REATING Date Receiptp
Q O I Plicum
z }IOTICIiTO PPLICANT:ILafterm "n t " enific'" ?x epti you shoal] NEW RESIDENTIAL PLMB. SQ.FT. 'TOTAL:
C+ becnmesuhjen otha Workers Cnmpen. i isions,��/'g9Cy7cet�m rCo amass
Pi , forthwith compl wish so hProvisin pe,,ti'y1��Ial W. BUILDING FEE
a �, C IONyDWMOENCY SEISMIC RE
Vz Thereby uffrm nucons����cti/s 3�len mg age for the perfonnmme of
O Newarkforwhichth pe it sisauW 097,Civ. „ ELECTRIC FEE �
0 (-r Ldes Namu
l-` 's Address QTY. MECHANICAL PERMIT' FEE PLUMBING TLE
V LeenaderrAddress 1 certify that 1 have I ad this application state that the above infomtation is ' y
�" 4 cored.lugrec tocomply Th all city and co ordinances and sate laws re1a0n8 to PERMIT ISSUANCE MECHANICAL FEE R ��
rA buildingconstruaion,end he byamhoris arsentatives of Nis city m enter upon the
V "� above-memianW properly for specs purposes. ALTER OR ADD TO MECH. CONSTRUCfIONTAX
(Wc)agree m save,indent and keep harmless the City of Cupeninu against
Iiabilitia,judgmenB.cosB andexpcnseewhichmay in anyway accrue egvnst snid City AIR HANDLING UNIT(TO E)."CFM)
I.umuyuence of the grvning of this permit. MR HANDLING ON IT(OVER ILON)CFID f
Signature of Applicam/Conttacmr - Date EXHAUSTHOOD(W/DUCD finow _ PAID
HAZARDOUS MATERIALS DISCLOSURE HEA'PING UNIT(TO 100,001)BTU) Date Receipt#
Will the applicant or future building occupant store or handle trunchons material
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety GRATING UNIT(OVER IN),IXNI HTU) TOTAL:
Cade,Basion 2553200?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
Will Neapplicunt nrfumrc MtiWingoccupom useequipmenmrdeviccawhichemit
BOILER-COMP(3HPOR IN,"BTU) ISSUANCE DATE
Iddliki 1 hmardcar air<onuminuts as defined by the Bay Am Air Quality Management BOILER.COMP OVGR 100,000BTU
Dlnri100,000l )
El Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have mud the haurdom mmerials requirements under Chapter 6.95 of the JUN
I ln�l
Culiliman l Iealth&Safety Cade,Sections 25505,25533 and 25534. 1 understand thus �s1'�i
if the building does not currently have a tenant,that it is my responsibility to notify the ,
c am the requirementsich must be t rim to ixsuunee a rtilicate of ''I /
r I Iryo
mer or uutharirfe�r�d.gem 6 Ste
t*15 � ISSUEDBY:
OFFICE