26220 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL"; PLE(TRILA L PERMIT NO,
APPLICATION/PERMIT PLUMBN(:.MECHANICAL Lr)C n r)O
BUILDING DIVISION BUILDING PROJECTIDEN1 IFICATION UL G
BUILDING ADDRESS:/. , SANITARY NO. APPLICAIIO�N/SU,BMGTALDATE
IOWW UNITM LOTH ,-3 I�fN
O AMG: s, PHONE: CONTRACTORS NAME: LIC NO: N/C CONI ROLOr
ARCI TE NF R- LIC NO: ADDRESS: ❑
CON CT: PHONE:
QTY. ELECTRIC PERMIT AEE BUILDING PERMIT INFO
BLDG ELE�PI.UM� M'
PERMIT ISSUANCE 1 s,1
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
OWZ thereby uffmithal l um licensed underpmvisioneol'Chapter9(commencingwith TOB DESC0.IPOON
e100 Section?000)0(Division lof the Business and Professions Code,and mylicemeis in PANELS ww
Call force it effect.
QVC License Class LIC.p UP T020o AMT'S
H y Date Carriacou r 201.1000 AMT'S
Z Oy? ARCHITECTSDECLARATION SQ.FT.FLOOR AREA S/SQ.IT.
I understand my In hll be used public records. OVER 1000 AMPS
O Z-^O YPa plan.y .J SIGNS ELECTRICAL.
�w Licensed Pmfeuional
K OWNER-BUILDERDECLARATIONthe Commences
oATTON SPECIAL CIRCUIT/A115C.
�x' : V 1 hereby affirm that 1 em exempt from the Comm Co License law for the
W 3 Y.y following reason.it (Seita 1071;Bminas and improve.
de io demolish,
Cade:Any city structure
TEMP.METER OR I'OLP.INST. I
tz MV` which requires a Permit m conswct,char,improve.Jemolixh,or repair any strvcwm ll
>• m its issuance also re sthen applicant for such permit file a shared POWER DEVICES I '_
F prior yn the
PP permi BLo P t ) IF
Qp thin he is licensed pursuant to the)of Diiom of the Contractor'¢License law(Chapter
4 p�' 9(cammencing wiN Section]Olq)of Uivision3of the Buxineu eml Professiom Cade) SWIMMING FOOL ELECTRIC k VAI,UATIOIN
poly nr that he iseumpnhercfmmand the basis for the alleged exemption.Any violation of
C YOa OUTLETS-SWITCHES-FIXTURE
TE
S5 Section 7031.56 ireY dlicant fore Penni subleds theapIic nno.civil PenabY of
1 Zi
0I,enwnerofthepmprty,nrmyemployeexwithwagesuslheirolecompensation, NEW RESIDENTIAL ELELTR —SQ.
TYPE CONSTRUCTION
morethan ve hundred ollun(
y STORIES
willdo the work,and the structure i®at intended oroffc¢d forsale(See,10,14,Business
and Professions Cade:The Cammaors license Law does not apply to on owner of
property who builds or improves thereon,ad who dess such work himsclfor through his
ownemployms,provided that suchimprovementionenot imendedoreffered forsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is wild within one yerrofcmnpletion,the owner
builder will have the burden of praving that he did not build or impmve foe purpose of TOTAL:
1 wneroftbeproperty,amexclusivelyeontrueting with licensed contract n to QTY, PLUMBINGPERMIT FEE FLOODZ NE APN
the project(Sec.70,44,Business and Professions Code:)The Contractors
License Law docs not apply to an ownerof preperry who builds or improves thcmon,and PERMIT ISSUANCE
whocnmracn for such pmjectswithacentractor(s)licensed pursuant a the Conuactore ALTER-DRAIN&VENT-WATER(EA)
l.icenwp�� FEE SUMMARY
❑ I U axe t under Sec. .B&P fm tis reason BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Deb DRAINS-Fl,OOR,ROOF,AREA,COND. RECEIPTN
WORKMAN MPFJVSATION LARATIO SCHOOLTAX Y N
❑ Thereby affum thm lhaveacenificam ofcon wolf-insum,ora cenifcateof FIXTURES-PER TRAP RECEIPT
Workera Campensntion lasumace or acetified copy thereof(See.38M,Lab C.)which PARK FEE Y N
covers all employees under this permit. GAS.EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy g BUILDING DIVISION FRES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHF.CK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with theciry inspection division. GREASEANDUSIRL.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars IS IW) SEWER-SANITARY-STORM EA.200FT, ENERGY PER
mless.)
Ic in the performance of the work for which N' pe it is issucd,lshall WATER HEATER WryENT/ELECTR
not amp cy y non in a an
to became ul1' Workers' PAID
Compenmtit Lint jfor, an — J l9 WATER SYS'TEM(fR1iAI1NG Uate Receipt Jr
0 z Applicant t.� �{
z NOI'IC3T PLICANI':11.after in ng this Comfit e f Exemption,you should NEW RESIDENTIAL PL.MB. SQ.R. TAI:
t--s become sabjet to the Worker's Compensation provisiod the Lahr Code,you must
tai forthwith comply with such provisions or his permit shrill be deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
rR+ I hereby affirm that them is a connrvedon lending agency for the performance of
U 0 the work for which this permit is issued(Sec.3M,Civ.C.) TOTAL: ELECTRIC FRE
Lcndcrs Name PLUMBING PEE
C) U Lenders Address QTY, MECHANICALPERMIT' FEE
I comfy that 1 have read this application end state that the above information is
F a correct.In agree In comply with all cit and ordinances and state laws Blatin to PERMIT ISSUANCE MECHANICAL FEE
g pyhe yon y g
buildingconstruction,
military
hcrehyaection rtrouti. Lives of thiacirymcmerupon the
O 'z above-me)ionedprepenyfor inspection purpose. AI:IER OR ADD TO MECI I. CONSTRUCTION TAX
(We)agree t save,indemnify rs.keep maylairraloo,a the Ciry of Cupertino against
liubilitie,judgmrna,costs and expenses which mayinany way acerve against¢aid City AIR HANDLING UNIT(TO IO,RfXI CFM)
in consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,00)CFM)
Slgnatum of Applicant7Contractor Date EXHAUST I[DOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(X)BTU) hate Receipt Or
Will the applicant or future building occupnt store or handle hanrdous notarial HEATING UNI'((OVER I00fKK16TU
as d.fned by the Cupertino Municipal Cede,Chapter 9.12,and the Health and ,
Safety ) TOTAL:
Cade,Section 25532(ml
Ye P(No VENTILATION FAN(SINGLE RESID)
❑
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will thenpplicantnrfmurchuildingmcupam uscequipmenlnrdevicexwhich emit qq p
hazardous air condominiums as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) tP W
DinrieC
- ❑Yes NEW RESIU[NTIAL MECH. SQ.PT, q&+,
�y —'�I have mad the hunfdous materials requimneno aider Chapter 6.95 of the R Q 1994
Odis Health&Safety Code,Sections 25503.25577 and 25534. I undersnnJ that C!�
ih ebuil does not currently have tenant,that it ismymsponsibility to notify the Vh
c pe of tl rcyrimmene which u t I/v t prior m issuance of Cc ficate of (¢I//"�
occupa cy. a 3 ��
Own. uthadud agent Dte TOTAL.: ISSUED B
OFFICE