26229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mnEDIST77 L¢c"TnT. PERMrr ND.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n[x n 6� (�
BUILDING PR(kJECI'IDENT'IFTCATION L o G L J
BUILDING ADDRESS: SANITARY NO. APPLBATDONSURMGTALDATE
UNIT# LOTH /
OWNERS NAME: PHONE.: CONTRACT R'SN M& LIC NO: I
Z' a♦[� ��� ,� 0 N/C CO IROI.p
'•ARCH['1'ECDENGINEER: LI'CI NO: ADDRESS: ❑
CDC // PHONE O 6-8,/O: BUILDING PERMIT INFO
e/ , QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] 9
( 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I paZ Iherebyaffinnlhas l sex licensedunder pevisimaidChuper!)hommencing with
FO2 SeamonV00tpofDivision 3nfibeBusiness and ProfessioalCarl and mylicenseisin PANELS ^' S�e,J�-a—
�IDf-. fall fore,indeffect // 1T)
Zod Licenses Li<.g �� f00 IIP T0200 AMPS
may DUIC r Can CIOr 201-1000 AMPS
FyZ HTI'F, SDEC TO ARAt-tbF `^� $/SQ.FT.
ZOyz OVER 1000 AMPS
OZ�O tattle blit recall
IGNS
dy U Licen Icssionel SPECIAL CIRCUI I ;
Saiulda OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xxOy� 1 following
greas affirm that I am exempt from the Contmcs Co License law for the
I+13LLm whowingremon.(Seatoto l03LS,Business and vefeuiana Code:Any.I,an scovary TEMP.METER OR POLE INST,
�O; which mquiresaperit mennswe6 eheq improve,demolish,or repair any shucnue POWER DEVICESDAT
}� prior to its issuance.also requires the applicant forsuch Permit m file a signed emtement
pp the,he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a- p 9(conuncncing wish Section 700B of Division 3 of the Business and Professions Cale) SWIMMING POOL ELECTRIC VALUATION
or that he is exemp nherefromandthe basis far the alleged x.ourption.Anyvioliameaf OUTLETS-SWITCHPS-FIXTURE$
�< Section 7031.5 byunyapplicanl(oru permit subjectstheupplicam to a civil penalty of
W mnot more than five hundred Dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT.
C1I,Csownerofthepmperry,ormyemployaswithwuguutheirsolee mp mmion, STORIES TYPECONSTRUCTION
a will doihework,and the structure is munnended oreffemd Russia(See.T)qq Business
and Professions Code:The Contractor's License Law does not apply to an owner of
properly wbobuildsorimprnves thereon,undwhodoessuchwork himsedfortluoughhis OCCGROUP RES.UNITS
own employces,provided that such improvements me not ineended or offered for sale.If,
however,the building or improvement is sold within au yearofcompletion,theowna- TOTAL:
builder will have the burden of proving that he did not build or improve for puryose of
sale.).
❑ Lasownerol the property,an excluaivelycoltructingwinh lieenudconoactonto QTY. PLUMBING PERMIT FEE Fl.00DZONE APN
Orme,the project(Sec.7044,Business mad Professions Code:)The Comrecmr's
License Law doesnot apply toanawnemfpmpeny who builds in improves nherean,andPERMIT ISSUANCE
m
who comas forsuch projects with a emorudor(s)licensed paramount no the Contractor's ALTER-DRAIN&VENT-WATER FA
License law. (- ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dna DNAINS-FLOORROOPAREA,COND. HEHIPTF
WORKMAN COMPENSAT , ,
ION DECLARATION . SCHOOLTAX YN_
• ❑ I hereby affirm that l have a certificate ofecaun e
senself-insu ,or a Gnifcatoof FIXTURES.PER TRAP RECEIPTM
Workers Compana
ensation Insurance oranified copy thercoa
f(S .3800,Lab C.)which PARK PEE Y_N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT g
Policy al BUILDING DIVISION FEES
Company
❑ Gertlfled copy is hereby famished. GAS-EA,SYSTEM-OVER 4 HDO PLANCHECK FEE
❑ CeniEed copy is filed with the city inspection division. GREASFANDUSTRL WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE YRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed not b,completed ifthe permit is porous hundred dollars($UxD SEWER-SANITARY-STORM EA.200FT. O ENERGY FEE
or leu.)
I cenify that in the performance of the rk far which this Permit is issued,l shall WATER HPATER W/VENT?LECfR
nut employ any pc manners h oma stM1jat� h Workers' PAID
Compensunion't+��� f WATER SYSTF.M/IREATING Date Receipt it
z A licant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RFSIDENTIAL PI.MB. SQ.FT. TOTAL:
L-1— U) become subject to the Worker's Compensation provisions of Ne fahor Code,you must
FRa > forthwith comply with such provisions or this peril shall be deemed evoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I hereby affirm that them is a emouniction lending agency for the performance of
O the work far which this permit is issued(Sec.3ND,Civ.C.) TOTAL: OV rLELTRIC IEE
Lcndeea Nome PLUMBING TLE O
p L) Lenders Address QTY. MECI IANICAL PER MIT FEE t
I certify that 1 have read this application and state that the above information is
CLI toner.J agree to comply with all city and county ordinances and state lows relating to PERMIT ISSUANCE MECHANICAL FEE
_ L,0 building construction,and hereby authorize mpteuntmivesofnhis city to enter upon the
U ahnve meniioneA proper for inspection policies. ALTERORADDTOMECH. CONSTRUCTION TAX
(Wc)n 0 s indemnify and keep harmless the City of Cupcninn against
liabilitic gmen sH end expgleQ which may in any way accrue against said City AIR HANDLING UNIT(T010,0011 CFM)
in to enc Ih gamin thi it.
n AIR HANDLING UNIT(OVER IO.fIIMI CM)
ignarumof ApplicanVContraaor Dart EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 RTU) Date ReceiptN
Will the applicant or fumre building excursion stem or handle hazardous material HEATING UNIT(OVER 1(0,1X10 BTU) TOTAL ` s �
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I Iealth and Safety
Code Section 25532mr?
11 Yes 13 No VENTILATION PAN(SINGLE RPSID)
DATE
BOILER COMP CUP OR 100000 BTU) ISSUANCE
Will the ampplicaorlmm - ,
ure buildingoccupem uxealuipmem ordeviccs which PAID
luxurious air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1(10,(X10 BTU)
. Diund'1
❑Yes 0 N NEW RESIDENTIAL MECH.-SQ.PT. APR
.. A -IflI�/1
1 have read the Imnrdaus mmerials requiremems under Chapter 6.95 of the P'1P Y IJJ`P
California Health&Safely Code,Sections25505,25533 and 25534.1 understand that CITY yr wren+lou
if the bui Wing does not currently have a tenant,that it is my responsibility to notify the
aecupem of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
—tb
Owner or emhorixed ugemDate TOTAL: ISSUED BY: U W
OFFICE