26202 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- L al AL PERMIT NO. 26202
APPLITI /PERMIT PLUMBING-MECHANICAL. _
BUILDING DICAON
VISION BUILDING PROJECT IDEN'TIN'ICATIIIN
BUILDING ADDRESS: SANITARY NO. (APPLICATION SUBMJTFAL DATE
UNIT# LOT#
OWNERS NAMP.: PHONE: CONTRACT'OR'S NAME: LIC NO: V
NIC CONTROL#
. RCHI 'CI'BNGINEEW. LIC NO: ADDRESS:
El
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
yt y JI O BLDG E PLUMB MECH 01- s PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATIONApp1.lANCES RESIDENTIAL JOB DESCRIPTION,
nwz I hereby affum Nat l vat licensed underpmvisionsofO pter9(commencingwiN
Fs d full fon e and)e f Division J of the Boniness and Professions Code,and my license is in PANELS
K Cpp�E Lican rceandeffect.
6 License Class Lie# UP T0200 AMPS
Data Canwnor 301-I"AMPS SQ.FT.FLOOR AREA $/SQ.FT.
zOvz ARrTAJV
CHITECTS DECLARATION OVER 1000 AMPS
O Z"O I understand my plans shell be ural as public records. /k }•�•� /�
ranL� SIGNS ELECTRICAL
Q SS�dd�J
Licensed Professional
rylV OWNER-BUILDER DECLARATION, SPECIAL CIRCUFUMISC.
O,U 1 hereby off.that I um exempt from the Contractor's License Law for the
31r-m
following rcoser.(Section 703 1.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to concoct,alter,improve,demolish,or repair any structure
}� priomo its mocerce,also requires Ne applicant for such pemduo file a signed summer POWER DEVICES
4] a p that he is licensed personal tome pro,kiom of the Coarommrs License Law(Chapter
s o� 9(cotmnencing with Seetion 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC �� V {-Up DO
_y or that he is exempt therefrom and be basis finch,alleged exemption.Any violation of ��
z} Section 7031.5 by any applicant for a permit subjects the appUrtat to a civi,orom of 11. OUTLETS-SWITCHES-Fl%TURFS
O not me than l.fthom ndreddallvrs(5500). NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
�p ❑ .thewrk,anforoperty,ormyemplruded rthwegesastbe(Sm. 0414,Bom.co,
a will do0sewons and theso C. isnmintendedor awdoor,fficred moaply.. 4,Business
and Professions wh obu Code:The improves
the ton,Liana law does or apply.. owns of
propertywhobuiIdsor mantesthereon,trodwhodosouchwork rfthroughhis
ownemployces,provided that suchimprovememsurcnot immndedoroffoffiercdforsele.If, OCC.GROUP RES.UNITS
however,the building crimpmvement issold within oneyearof completion,theowner-
builder will have the burden of proving that he did oro build or improve far purpose of
sale.).
❑ I,asownnrnfthepma ay,emexclusivelycommetingwilhlicenudcont etomto QTY. - PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sm.7044,Business and professions Code:)The Counselors PERMIT ISSUANCE
Liana Wwdasnmapplymmownerofpmpmywhobuildsorimprovesthereon,and
who commutes for such projects with aconuvmOs)Iicemecipursuant mthe Contractors
License[.as. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I not exempt under Sec. ,B&P C for this..on OUTSBACK FLOW PROTECT.DEVICE ID -
SANITARY Y N
Owner DamRECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND. SCHOOLTAX Y N
❑ IhercM1y uffrm thutlhaveeanifcate of consent mselGinsure,orncenificete of pl%TURES-PER TRAP17 RECEIFF#
Workers Compenmtion Insurance caracertified copy thereof(Sec.3g00,Lab C.)which PARK FEE Y
covers ell employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DTV ISI
Company GAY'EA.SYSTEM-OVER 4(EA) PfANCHECK FEE
❑ Certified copy is hereby banished,
❑ Cmified copy is filed with the city impaction division. '
REAS R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHAS P g j SOILS FEE
COMPENSATION INSURANCE
(This section read at he completed ifthe permit is Tann hundred do[]..IS I Off SEWER-SANITARY-STORMEA.200 ENERGY FE
or less.)
I maifyffim in the performance of the work for which this permit is issued,l shall W TER HEIMT�EENT/ELECR
not employ any person in any manner so as to become subject to the Workers PAID
Compensmionlawsof Califomis. Dam WATER SYSTEMfrRRATING Ua Raceiptp
O Z Applicant
zzf�-I C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENUAL PLMIL SQ.FT. TOTAL:
F-� IA become subject to the Worker's Compensation provisions of the labor Code.you must
1a 7 forthwith comply with such provisions or this permit shall be deemed mocked. BUILDING FEE .��
Ua CONSTRUCTION LENDING AGENCY ASEISMIC FEE
Z I hereby affirm that there is a convection lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) T ELECTRIC FEE
lsnder s Name
u"
O Lender's Addmsa TY.• MECHANICAL PERMIT FEE PLUMBING FEE
E" - Q '
LUkI1 cenily that I have red this application roti slam that the above infommtus is MECHANICAL.FE
correct.T agree to comply with all city and county ordinances and stem laws relating to PERMIT ISSUANCE
DO buildingcomtructim,and herebymthodmfthis teptemmovesacity To mmrupon the CONSTRUCTION TA
DO
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgromew,costsandexpenses which may foamy way amme against said City AIR HANDLING UNIT G 010,"CFM)
in c.o ence ofthe gtmting of permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
^1
Signe pli<enU umract Data EXHAUST HOOD(WNUCf) PAID
gp
�V✓�
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 1011,030 BTU) Dem #
Will the applicant or future building occupant store or handle Invaccous conatenal
as definW by the Cupertino Municipal Coda Chapter 9.12,anti the Health anti Safety IIP.ATMG UNIT(OVER 100,000 BTU)
Code,Section 2553200? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COST LIHP OR 100,001)BTU) I$$j1A TE
A�CID
Will the upplicnm or fmurebuildingmcupvn useequipmentordeviccawhiehemit 110
Imeardom sir emporiums as defined by the Bay Ares Air Quality Msomemem BOILER-COMP(OVER 100,000 BTU)
1Nf1' MAR 28 1994
❑Yes ❑No NEW RESIDENTIAL MECI{. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of te
h /s
California Health&Safety Code.Sections 25505.255]3 and 25534. 1undersand That VII r Vr vuYCfI I IIYu
if the building does not currently have a mnmt,that it is my responsibility to notify the
copmt of the requir mens which must be at prior to issuance of a Cenifiame of
cc
OuPmcy. e
Owner orsuthorized ag<m Data IT ISSUED BY:
OFFICE