26921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIIIf.DINC-E"t."RTGAI. PERMITNO.
APPLICATION/PERMIT PI.IG PROO-MF.CHANIFIC 26921
BUILDING DIVISION BUIhDINC,PNUIF.C1'IUP.NI'IF1CA'I'lON
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
o WA e(4 CIE VtL UNIT# LOT 9/
12.2.,q%f
NF.RS NA E: PHONE: P NT CfOR'S NAME:
iLIC NO: CONTROL#
C /f NAJToL v fn-ri�vo
ARCIIITF.CTRiNGINHHR: LIC NO: DNESS:
7/jeF, tEvFl#✓/✓E 'VAIf C
CONTACT: PHONE: Qom. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG EVCT PLUMB MECH
PERMIT ISSUANCE / IL-'-IT,
LICENSED CONTRACfOR'SDECGRATION APPLIANCES-RESIDENTIAL JOB DESCBJ�IjgV
1402 Ihneby affrthn l 3 ofth Bussed iness
and rifesion$Code,a(co mmencing with
tjd0 Section7000)
and effect.Division 3of the Business end ProfessionsCde.and my license is in PANELS
�Z LicFall ense
fat. 1
F license Class Lic.# l UP T0200 AMPS
H=y Dale Contra,or. 201-1000 AMPS
ZOvSZ ARCHITECTS DECLARATION OVER I"AMPS � SQ.PT.Fp1•,•0�0R ARGF� � S/SQ.IT.
r V 2 Licensed Pmrsum cssion p �us s ubYc rx J SIGNS ELECTRICAL II F L Il I N l
JC,T OWNER-exempt from
DECGRATION SPECIAL CIRCUIT/MISC. 'I rL Ill •.�✓� �VVV
g fi 1 hereby off.that 1 ER exempt from the Contractors License Lew for the - �. I-,
u03 following crown.(Sectinn'I031.5,Business and Professions Code:Any city ormunty TEMP.Mi OR POLE INST. "? U
�' which requires a peril m construct,ahem improve,demolish,m repair any soactum
!!(Y� pnonoitsism.rea,lure Tres the licnm far such t m flea signed mmmern POWER DEVICES
i 9b PP Iwura 8 E
ty pz Nm he is licensed pursuant to the pmv ivisi of the Camrutm's License Law in,C den
�W , or(that nets exem tterefrm aW)of Division Sof theed exemption.
violation
ms Code) SWIMMING POOL ELECTRIC VALUATION
lyan or heir 1.5 by aherefmmandthe bermitsbjthe asegedeaempts to civil Penalty
of OUTLETS-SWITCHES-FIXTURES
tZa Section 703 not more
than five
by mYdreddmtfor a rs($50rit subjects the npplicmtmacivil penalty of
AZO 1,.,hanfl.fibe hundred dollars NEWRESIDENTIALELECIR -SQPI'.
❑ LasowneroDheprnpeny,omycmployeeswith wagevastheirsolecompensation, STORIES TYPE CONSTRUCTION
cJ
a will do the weri and the structure isnot intenddoroffered for We(Sm.7044,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
propenywhobuildsorimprovestomme,and whodoessuch work himseifurthmughhis
ownemployees,providedthat mchimprovetnemsammt intnMedorofferd for We.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearufasmpletion,the owner- r
builder will have the burden of proving that he did not build or improve for purpose of
sale J.
[1I,asownerofthe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEF, FLOOD ZONE APN
concoct the project(Sec,1014,Business and Professions Code:)The Commuters PERMIT ISSUANCE
License Law does not apply tomo tuner o f property who bui Ids o improves Hereon,and
who colnmcp forsuch projects with a conncor(s)licensed pursuant o the Contractors gLTER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fo this mason HACK bLOW PROTECT.DEVICE TS D
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOP AREA,COND. RECEIPT
WORKMAN COMPfJJSATION DECLARATION SCIIOOLTAX YN
❑ Ihereby affmmlhatl have a certificate oflomma,,self-homi'ooa cenificam of RECEIPT#
m
Worken'Copm
ention lexaminee o certified nified copy thereof(Sm.3800,Lab C.)which � �ES-PER TRAP PARK FEE Y-N
-
covers all employee's under this Perin GAS-EA.SYSTEM-1 INC.4 OUTLETS - RECEIPT#
Policy If BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifled copy is hereby famished.
❑ Certified copy is fled with the city inspection divinna. GREASE/INDUSTRL WASTE.INTF.RCEM OR GRADING THE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP SOILS FEE
COMPENSATION INSURANCE
(This section reednot beccmpletd ifthepemdt iaForms hundrddollan($100) SEWER-SANITARY-STORM EA.20ficl'. ENERGY FEE
colas.)
I cenify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ my person in any mater so as to bxmme subject to the Workers* PAID
z Compevatiot Lawsof California. Data _ WATER SYSTEM(TRGTING Doe ReceiplIF
Q Applicant
O
�c�cii--II NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.PT. TOTAL:
C+ � subject become subjeco the Workers Compensation provision ofthe labor Code,you must
lir , forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
Q7-. CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a construction lending agency for the varknrance of
V O the wok for which this pemdt is issued(Sm.3097,Cu.CJ TOTAL: ELECTRIC PEE
Lk. Lenders Name
O Lenders Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
L) I certify that 1 have recd this application and sate then the above infomuticn is
>" totem.la,mamcomplywithallcitymAeounty odinances and state law,relating m PERMIT ISSUANCE MECHANICAL FEL?
_ Cn bulldingcoustrunion,and hereby authorize representatives ofthiscily to corer upon the
V Z nlwve-mentioned property for inspection purposes. ALTER OR ADD TO MSCI I. CONSTRUCTION TAX
(We)ague m save,indemnify and koep harmless the City of Cupertino against
liabilities,judgmenss,costs and expenuswhich may in my ways Baines said City AIR HANDLING UNIT(TO Ift"CPM)
n consequence of the grmtiag of do peril. AIR
(vim AIR UANULINO UNIT(OVER 10,000 CTM))
Signumrc ol'Applicam/Commctnf Dk EXHAUST HOOD(WMUC I PAID
IIA2AROOl15 MATERIALS DISCLOSURE HEATING UNIT(TO 100,p00 BTU) Data Rc7,,,#
Will the applicant or future building oecupanl store or handle hazardous material
as defined by the Cupertino Municipal Cotte,Chapter 9.12,and the Health and Safety HPATING UNIT(OVER 101 BTU) TOTAL:
Code,Section 25532(a)9
❑Yes ❑No VP TILATION PAN(SINGLE RFSIO)
BOILER-COMP(LIP OR I0(I,"BTU) ISSUANCE,DATE
Will theapplicanto(uturebuildingocupamuuequipmrnlordevices whichemit (� p
hm'ohm. it contummarms as defined by the Bey Arm Air Quality Managmoral BOILER-COMP(DVP.R 101,000 BTU) n N
District?
❑Yes 0 N NEW RESIDENTIAL MECII. SQ.FT.
1 have red the hazardous materials mr,mmments under Chapter 6.95 of the AUG 2 21994
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that CI
if the building does not currently have attract,that it is my responsibility to notify the /
capon cf the requirements which must he met prior m isauance of a Certificate m' Y ser LUr
Occupancy. Lt
CTI///d s
Ownernrmolhoo elugem Dale TOTAL: ISSUED BY:
OFFICE