26208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO MIIAI ,-LL.. RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26208IIUILDING PNlSJF:T,'1'll]BNI'IFICAT'ION
BUILDING ADDRESS: - f( 4 0.' SANITARY NO. AMICA11l0N�SUUHHMITTA�LDATE
W csj 1 1 1 ) 1 I IYes UNIT N'(p 2J LOT M
O E A �: 1t21n� PHO is CONTRACTOR'S NAME: LIC
NN`O/ N/C
• ANCIII'1'ECI'/ENGINEER: l• LIC NO: ADi BSS:O ` ��Vs�IU r/rG t�L�� ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
O y 2 I hereby affirm that l an licensed underprovisions ofatipter9com
( meacingwith JOB DESCRIPTION
POO Section 7000)of Division 30fthe Busineseand Professions Code,and my license in in PANELS
� full force and a fcer. /1��// �+
F,Z License On, — Lie.k Z4(X_Z II UP10200AMPS
Qy Date Convector 201-I"AMPS
ZDyZ ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA ,$/SQ.FT.
OZ-0 l undcrsmnd my plans shall be used as public mcards.
a'y J LianaNProfessional SIGNS ELECTRICAL r ALE D IN
alcv,Q OWNER-BUILDEromthe ARATION SPECIAL CIRCUIT/MISC. . e
XOaF.., I hereby off that I an exempt from the Conwgors License law enr the U
W 3 W m following reason.(Section 7071.5,Business and Profen imu Code:My city orcoumy TEMP.METER OR POLE INST.
TER
which requires u permit m nmswa,alter,improve,demolish,0r repair any suucmre
a�
pror n its issuance.also requires the applicant for such permit to file a signedsmtement POWER DEVICES b
RI O O that he is licensed pursuant to the provisions of the Comachads License law(Chapter
d0.o� 9(commencing with Section 7")01'Division30fthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W y orthathe isexempt therefrom and Nebasisfortheallegedexemption.Any violation of OUTLITS-SWITCHES-FIXTURES
�a4 Section 7071.5 by any applicant fora permit subjects the applicant maeivil pximityof
net come than five hundred dollars(5500).
CCS ❑ I,asawnemfthepropeny,ormyemplayxawith wagavtheirsalecampensation, NE.WRESIDENDALELECIR _SQ.PT. STORIES TYPE CONSTRUCTION
y 3.. will do ihework,and the svuetureNstn imendedmoffered hostile(Ser.7044,Business
and Professions Code:The Contractors License law does not apply m an owner of
property wh0builds or improvesthemon,and whodoessuchwork himulfor droughhis
If. OCC.GROUP RES.UNITS
own employees,provided that sucM1 impmvcmems ore raw imm�ded or offcmd for sale.
however,the buildingor improvement is sold within one yearofcampletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las ownerofthepmpeny,an exclusivelyconwning with licensed contrecmmm QTY. PLUMBING PERMIT FEE FLOODZONE APN
anxrmet the project(Sec.7o44,Business and Prnfessoms CWe:)The Contrimm's PERMIT ISSUANCE
License Law does not apply to s n ownerof propery who bei Ids 0r im proves thereon,and
whocontracts for such projects with acanractons)licensed porauanuothe Courarr is
Licenm Law. ALTER (EA) FIE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE U SANITARY Y D L N
Owner Date REC[1P1'M
WONKMAN COMPENAT
SION DECLARATION DRAINS-FLUOR.ROOP,ARPA,COND. SCHOOLTAX YN
EJThereby affirm thmlheve ncertifcam of conxmto mlf-insum,macertificate of FlXTURFS-PER TRAP RECF.IPTp
Workers Compensation Insurance or acciified copy dumcf(Sce.38100.Lab C.)which PARK FEE Y N
covers all employee'sypppplhi�r�tG2 GAS-FA.SYSTEM-1 INC. OUTLETS RECEIPT at
Palicyp - r.. YY(( BUILDING DIVISION FEES
Company pct PY.i T�tflf-P,�TS
[�- Cenified copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE.
❑ Certified copy is filed with the city inspection division GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERIIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need not h completed Urns penNt is foronehondrcd dollars(SIf10) SEWER-SANITARY-STORM P.A.200FT. ENERGY IFI?
or less.)
I certify that in the performance ofthe work for which this Permit is issued,i shall WATER HFAI'ER W/VENT/ELECTR
not employ any person in any manner sa as to become subject to the Wicker% PAID
z Comlmnsation Laws of California. Date WATER SYSTEM/TREATING Dam Receipt
Q O Applicant
zz�-1 NOI'ICWI0APPLICANT:If.of.,making this Ccmficeteof Exempdogyou should NEW RESIDENTIAL PL.MIL SQ,FT. TOT
!'"Habecome subject to the Worker's Compensation provisions of Me Labor Code,you most. 7 forthwith comply with such provisions or permit shall be dammed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z i hereby affirm that hem iso c m,mial n lending agency for the performance of igE
TOTAL: ELECTRIC FET:
V O the work for which this permit is issued(Ser.3097.Civ.CJ
I.Mers Name
Q U Under's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 terrify that I have mad this application and state that the above information is
coram, degree to coat county g MECHANICAL FEii
comply hereby authorize
count tativecesand state lawsr upon m PERMIT ISSUANCE
U-' y amveng ntionectiomand herebyauthodm represemativesofthis city memo upon the CONSTRUCTION TAX
(� z abnv(We)geed psave, fmmnify ion purposes. ALTER OR ADD TO MECH.
(We)agree nt save,indemnify and kap hernoleamay
the City of Cupandoo against
liabilities,judgments.granting expenses
pared.hmay loony way accrue against said City AIR HANDLING UNIT(TO 10,0011 CFM)
in concerti he grunting of drie permit.
,tea AIR HANDLING UNIT(OVER IQggI CFM)
Signs pP' U radar Data- EXI MUST HOOD(W/DUCF) PAID
HAZARDOUS Ii'ALS DISCLOSURE. � HEATING UNIT(TO IW.000 BTU) Date Rccei
Will the applicant or fvmre building occupant entre nr handle haxurtlnus material
m defined by the Cupenirm Municipal CNe,Chapter 9.12,and the Healsh and Safmy HEATING UN[]'(OVER 100,000 BTU)
Code,Section 25532(a)'1
13 Yet, 11 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 111(1,000 BTU) ISSUANCE DATE
Will Neapplicamnrfumre huildingaccupuntmeequipmcnmrtlevices whichemit
hmard0us as commitments as defined by the Bay Ama Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Disvh.7
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. py
I have rental Ore huzarduus materials maimmmems un0_def Chapter 6.95 of the B
California I leahh&Safety Code,Sections 25505,25533 and 25574. 1 understand that
ifthe equallol the osmotcurremlyhave..I Fa met it myrtspnceoila Calfinotify tor (IR (des ��
Oc upnnt ol'the royulremente which must h0 met pdm m issuance of a Certificate of /y aFj a�
Occupancy.
CITY ur
Owner nr mnhorized agent Date TOTAL: ISSUED BY:
OFFICE