26738 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO stam G-ELECTRICAL PERMIT NO. 26738
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BUILDING DIVISION APPLICATION�PERMIT PLUMBING-MECHANICAL 2 6 7 K 4
BUILDING.PROJECT IDENTIFICATION L V J V
BUILDINPR
ADDRESS' - SANITARY NO. APPLICATION SUBMITTAL DATE
O UNIT IT LOT# 1
OWNER PHONE: CONT CIYJR'S NAME: LIC NO: l
• I J� as ®�� _ NIC CONTROL#
R TLIC NO: A SS:
CONTACT: PHONE: JI BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ V 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pay I hereby affirm that l am licensed underprovismosof Chapmr9(commencing with
00 Section 7000)ofnvision 3 of Ne Business and Professions Code,and my license is in PANELS �I/� ,�
C N full force and effect a^.,Ii11�7"ta",P7_s/✓
LoDatense�Lic.# a UP T02W AMPS
vFi Q y Date Comracmr 201-1000 AMPS
yFO 4 ARCt11TECT5 DE A ION OVER 1000 AMPS SQ.Ff.FLOOR AREA $15Q.FE
OZ-0
1 understand y plum,hall be used es public records.
F y tat SIGNS ELECTRICAL
g oi: License)Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
NO I hereby affirm that I an exempt from the Contractors License Lew for the �pqq
Y13 0 n, following reason.(Seen..7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. �� f L -, D @ N
PJ ao n which requires a permit to consumer,alter,improve,demolish,or repair any structure ^ ^ ^ '—
Y7 ono its issuance,also the applicant forsuch permit file a signed statement POWER DEVICES II�J I`.lr
Ari requires pp pemri g ( 1
0 p that he is licensed pursuant to the provisions of the Contcactov's License Law(Chapter
a' o� 9(aommenoing with Section"7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIO
ty Man or that he is exempt therefrom and the hosts for the alleged exemption.Any violmonof OUTLETS-SWITCHES-FIXTURES
7C Section 7031.5 byany applicant fora permit subjects fneapplicannoa civil penalty of
r� not more than five hundred dollars H1500). NEW RESIDENTIAL ELF.CfR _SQ.Ff.
Cm ❑ l,asowneroftheproperty,ormyemployeeswithwagesastheirsolecompemation, STORIES TYPE CONSTRUCTION
,3? the work,and thestmctnre is not intendedoroffered for sale(See 7044,Business
and Professions Code:The Comrectols License Law does not apply 0 an owner of
property whobuildsorimproves thereon,and whodoes such workhimselforthroughbis
OCO GROUP LRES.UNITS
howemployebuildivi carimatsochimpis sold itsarenot intendedmoffered forsalns,
however,the have
the
burden
of proving
is sold a didn of yearor improve
for thpurpose
of TOTAL:
builder will have the burden of paving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,amexcluslvely contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOODZONE MND
construct the Project(Sec.7044,Business and Professions Code)no Coatmemrs PERMIT ISSUANCE
License Law does not apply to an owner of property w ha bu i Ids c r improves thereon,and
who contracts bariumPancras with acomracmr(s)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE I E
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF.AREA.COND. RECEIPT#
TI
WORKMAN COMPENSATION DECLARAON SCHOOLTAX Y N
. ❑ I hereby affirm that l have a cenificate ofconeeat to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT IT
Workers'Compensation Insurance or a certified copy Himsef(Sec.3801 Lab C.)which PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy IT BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certifedcopyisherebyfumished.
❑ Certified copy is filed with the city inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nmbe completed ifthe permit is turn ne It dreddollere(SENT,) ER-S ITARY-STORM EA.2W ENERGY FEE
or less.)
I certify that in the performance of the work for which This permit is issued,l shall WfITIR HEATER WNENT/ELECTR
not employ any person in any rammer so as to become subject to the Workers' PAID
Com,speadm Lawsof Califomla. Date WATER SYSTEMIMEATING Date Receipt#
O z Applicam
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
q] becomesubjecno The Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or This Permit shall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm Not there is a construction lending agency for the porturacares of
U O the work for which this Permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's Name
O U Leader',Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE
>^ a correct.I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authorize representatives ofNiscity tocolor upon the CONSTRUCTION TAX
U z
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(W agree to save,indemnify and keep harmless the City of Cupertino against
liahi1 udgmente,c sae and expenses whit y in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
�n co ting of thi AIR HANDLING UNIT(OVER 10,000 CFM)
ignat of anVCommc to EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Receipt IT
Will The applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100i"BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Godo,Section 25532(e)P
El Yee Cl No VENTILATION PAN(SINGLE REBID)
ISSUANCE DATE
Will thea Iicamorfumre building turoe ntordevices whichemit BOILER-COME DHP OR 100,000 BTU)
PP g by he
quipme PAID
hazwdous air comaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dmldmi
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.EL JUL1 have read the huzmdous materials u quiremems under Chapter 6.95 of the JUL 12 ,g(u
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if The building does not currently have a manm,that it is my responsibility to notify The
CITY ccupant of the requirements whicM1 must be met prior m issuance of a Certificate of "I+, UY (fU(
Occupancy. j
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE