26055 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OPCUPERTINO BDII�INL=F. PERMIT NO.
APPLICATION/PERMIT PING BING-PROJECT IDHANIFIC 26055
BUILDING DIVISION BUILDING PROJF.CTIDF:NTIF'ICA'TION
BUILDING ADDRLSS: SANITARYNO. APN.ICATIONSUBMITTA�ILDATE
/ g/eUNIT# LOT#
OWN SNA :. PH7 CONTRACTOR'S NAME: LIC NO:
-E� r CONTROL p
ARCHITECUENGINEER: LIC NIL ADDRESS
11 Iv o or . .StT �
CONTACT: PHONE: -
9TYtaktn° �LECTRIG PERMIT FEE BUDDING PERMITINFO
BLgG ELECT PLUMB MECH
PERMIT ISSUANCE El El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby affirm hat l now licensed underprovisioru of CTapmr9(commencingwith
FOO Section 7000)of Division 3ofthe Business and Professions Code,and my license is in PAHHL
y� fall forceandel e)p Zl Lic.M �O 3 r / l/P T0200 Af.1Pg IQCAa,a—
6Z License Class /-
yaL Date�Conuaclor 201.1000AMPS
Z Orfeirz ARCFIITECTS DE J OVER IfpDAMPS SQ.FT.FLOOR AREA E/SQ.FT.
oz—aI understand my plan.shall be used as public.5 Ms. ..�
pyo SIGNSEFCITICAl h � ; .��
yy Liansed Profusiannl
OWNER-BUILDERDECLARATIONthe Ca ATION SPECIAL CIRCUIT/MISC.
W I hembY n.(Section
thrt 1 am exempt from the Conmmmr#License law for the
n1�+u-roe following reason(Semon 7031.5,Business and Professions Code:Any city,or county TEMP.METER OR POLE MST.
ce0 a which requires a permit to construct alter,improve,demolish,or repair any structure
or prima,its issuance,also requite than licant for such pemutto files signed statement FEWER DEVICES TE /
p Nat he is licensed pursuant to the Provisions of the Cornerstones License Law(Chapter
aao ' 9(commencing with Section 7")of Dwisim 3 of the Business and Professioru Code) SWIMMING POOL ELECTRIC VALUATION
WM, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
t4Q Section 7031.5 by any applicant for a Permit subjects the applicant w a civil penalty of OUTLBfS-SWITCHES-FI%TlIRES /'Z 5`Q• di�
f e nm marc than five hundred dollars($50%
W�m ❑ I,nsowneroflheproperty,mmyemployaawiN wagesastheiuolemmpanutlon. NJEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECOSTRUCION
y3� will dothework,and themmonimfsnot intended oroffered forsoe(SecJ0,14,Basin.,
and Professions Code:The Contractor's License law does not apply to an owner of r
property whabailds orimpeves Nermn,andwhadoessuchwork himselfarthroagh N9 OCC GROUP RES.UN
cmr.mebuldingdr improvement
Natvement rovld whom ne ewoecroplecred the le.
If.
huweer will have
burin. ofprovini that he whom or improve for theownen- .TOTAL:
builder will have the burden of proving that In.did not build or improve for purpom of
.to❑)Las nwneraf Nepropeny,mnexdusivelycammningwiNlicensedwnlrecmrsm 9TY:, PLUMBING PERMIT FEE FLOOD ZONE. APN
construct the project(Sec.7044,Business and Profea9iams Code:)The Commerce. ,
License Law doesnotapply m an owna,.f property who builds or improves thetean,and PERMIT ISSUANCE
who contracts forsuch projects with a con mmu(s)licensed pursuant the Commences
License Law. ALTER-DRAIN&VENT-WATER IRA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for his tenon BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY YN
Owner Date RECEIPT p
COND
AREA.. .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL TAX YN_
• ❑ IherebY affum thou haves certificate of mnuntmulgi...na,oracertificoteof FIXTURES-PER TRAP RECEIPT
Workers'Compema6on losurenceor a certified copy thereof(See.3800,Lab C.)which PARK FEE Y N
muco all employee'st thiggetmj{• O�- GAS-FA.SYSTEM-1 INC.4 OUTLETS - BUILDING DI ISION FEES
PalicyM YO
• Cert GAS-EA.SYSTEM-OVER PLANCHECK FEE
❑ Certified copy is here fumisheJ.
❑ Certified copy is filed with Ne city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SEA'S FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is former ($11)(1) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
ar lea9.)
I certify that in the performanceof Ne work for which this permit is issued,l shall WATER HEATER WARNWELECIR
oat emplay any perm. in my manner so u m become ubje a toXdaaas a Wohets' PAID
Campion I..Lawsof lifossda. Date WATER SYSTEMMEATING Date Receipt#
O O NOTICETO :.If,aOer making) is CeNficamof Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
UJ becamesubjauo the Workers Compensation provisionsofthe LaborCode,you must
� ; forthwith comply whir such provisions or this parrot shell be dam#revoked. BUILDING FEE -d0
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE91,
�--�
I hereby affirm that there is n combustion lending agency for the performance of
U O work for which Nis permit is issued(See.3097,Civ.CJ TOTAL: ELECTRIC FEE
Le
a� Lender's Name :T4
I u-' �+ QTV. MECHANICAL PERMIT FEE PLUMBING FEE
LendeI c Addreu
IU I certify that I have mad this application and state that the above information is ".,as " MECHANICAL FEE
L"' Oa correct. l ague mcomply with of city and county ordinances and slam laws relating to PERMIT ISSUANCE
�' In building construction,and hereby authorin representatives ofthis city to cater upon the CONSTRUC IONTA%
U Z above mentioned property for inspedim purposes. ALTER OR ADD TO MECH.
(We)agree m gave,indemnify and kap harmless the City of Cupertino against
Iiabilities,judgmems.costs and expenses which may in any way eccrueagarortmid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this 't.
r AIR HANDLING UNIT(OVER 10,000 CFM)
Si mo PAID
ApplicanUConra'or Date EXHAUST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IW,000 BTU) Data Racers#
Will the Ble Cape or finar,n.Municipal
Coreng ,
stem or hanand Br Health and Safety HEATING UNIT(OVER 100,"BTU) TOTAL: p S�
rial
u Defined by the Cupenino Municipal Cale,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(a)P
1:1 yrs 1:1 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(71IP OR Ifq,000 BTU7 ISSUA EDATE
Will lheapplicamor fmurebuildingoccupant auequipmenmrcicvicea which war,
hazardous air contaminants u dented by the Bay Area Air Quality Management BOILER-COMP(OVER JOLM BTU)
More?
❑yes ❑No NEW RESIDENTIAL MECH. SQ.Fr.
1 have read the Intimidator materials hislabcments under Chapter 6.95 of the
Colifomia Health&Safety Code,Sections 25505,25533 and 25534. 1 underm nd that
if the building does not currently have a tenant,that it is my responsibility to ratify the
occupant of the mquiumenta which must be .or m...more of a Croup..of
Occupancy. r' ��''
Ow uthoriud agent
Data TOTAL: ISSUED BY:� , �� �~ w