26999 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'B - - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PIAMBING-MF.CHANICAL 26999
BUILDING PROJE<'1'IDNNfIFICATION
BUILDING
�ADDDDDRRHESSS: SANITARY NO. APPIJCATIONSURNUTALDATE
LV 1 e� �.{� V vUNIT# LOT It
O ERS NAME: PHONE. CONTRACTOR'S NAME S L��: NIC CONTR Lp
ARCHITf: /ENGINEER: LIC NO: ADDRESS:1. i4p r A= C-- ❑
7a If+h"� LM t G/�•
Coirrncr: Pxorve:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
`R Iv BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
qa.Z I hereby uffirm that l an licensed underpmvisions ofCWpter9(commencingwids 10 DESCRIPTION
P302 Section 7001 of Division 3 of the Business and Professions Code,and my license is in PANELS
rce aof t
CtxI full fond . R #
aFZy`f License Clas Lic.is—*e � UP TO 20D AMPS
ti a a Date Contractor 201-1000 AMPS
20y� ARCIUEI=S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $1SQ.FT.
O Z— I understand my plan shall be used as public records.
MI y
ISI SIGNS ELECTRICAL
4
Licensed Professional
E$aI OWNER-exempt i orDECLARATION SPECIAL CIRCUIT/MISC.
yx OaO 1 hereby n.(Se that 1 am exempt frau she Cosions; o License Law for the
ul ti following reason.(Section 7071.5,Businessvandmpr Re,de Professions;Code:My city atcounty TEMP.METER OR POLE MST.
y
which rcyvircs i permit to consumer,aper,improve,demolish,a repair any sanctum POWER DEVICES
Y� #donessissuance,a....11th thevisinntf the Co permit to Liceseho statement
A O
to.,he is licensed with
S u do to the provisions of the Ce Business
License Law(Chapter SWIMMING POOL ELECTRIC
M, 9t(commencing
xemit therefrom
and thW)ofe
Division 3oftheed exemption.
iota Code) VALUATION
WZ orthat7031.5 by any
pplic nt fthe permit subjects
di.dexemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Z G not more
a th n iv any applicant fora permit wbjects the applicant m o civil penalty of
E
not ml,asown fivehundred
roMtyllarmyemp. Q STORIES TYPE CONSWUCDON
+•.O w. NEW RESIDENTIAL ELECfII S .FT.
yy m ❑ othewrk.andeestrucy,ormycmpinduclorthcand hotels
otels(sm.7W,Business
y3� will dothewonsCdthe he Contractors
License La emA fm not
7044,Business
and Professions Cade:The Cmnverenm ted who law does nor apply if an owner of
proown emrty whnii.proorid roves nonsuch
wensuchwoh himslfathroughhi, . OCC.GROUP RES.UNITS
own thprove impnry sold
wit in ne yearoedo platin .Tortola.owner.
huweer will ave the burden ofementiahat he id net build or improve for lhe urposc .p
builder will have the burden of proving that he did not build or improve for puryone mf
sale..
,vs ownnofthepmady,amexdusively convecting with liccnsedconvnmorsm QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
constmet the pmject(Sec.7044,Business and Professions Code)The Convector's PERMIT ISSUANCE
License Law inexact apply to an owner of property who builds a improves(hereon,and
whocantracts forsuch projects with accountants)licensed pursuant to the Contractor's ALTER (PA) - FEF SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE .S
SANITARY Y N
Owner Dam RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. —WZQQLTAX YN
❑ Iheteby affirm lhetihaveaartifican of wnsent to selGins......cenificateof FIXTURES-PER TRAP RECEIPT#
Worlaws'Compensarion Insurance or a certified mpy thereof(Sm380,lab C.)which PARK FEE Y N
cave.all era ftpJqyetiPgqyy��e GAS EA.SYSTEM I INC.4 OUTLETS this ^^ - - RECEIPT#
Policy p�lL {'�"�L( BU ING DIVISION FECg
C_onJP, GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
p'Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section r¢ed not be completed ifthepemut is formic hundred dollars($IN) SEWER-SANITARY-STORM EA.200FT. ENZ GY FRE
or less.)
Icertify(but in the performance of the workfnr which this permit is issued,l shall WATER HEATER WIVENT/ELECTR k '
not employ any person in any msnner so as in became subject to the Workers' P
Compensatimalawsof Califamia. Data WATER SYSTEM/IRRATING Do Receipt
Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ. TOT
,r fA become subject o the Wohds Compenssamm provisions ofthe labm Coda.you must
�i 7 forthwith comply wish such provisions a this permit shall bem
e deed revoked. RN
FEE �•
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of as
O she work for which this permit is issued(Sao.3(97,Civ.C.) TOTAL: ELECTRIC ME �
Lenders Name
OLeadds AddressQTY. MECHANICALPF.RMIT FEE PLUMBING FE
I certify that 1 have tend this application candidate that be above informition is M NIC .FEE
0W rest.l agree in comply with all city and county ordmncea and soon laws mlatingto PERMIT ISSUANCE
uddingconswction.and hereby authmdu representatives ofthis city toenterupon the
Vi bCONSTRUCTION TAX
(„) G77 above-mentioned property for inspection and kne,pee. ALTER OR ADD TO MECH.
(We)ugu nt save,indemnify and keep may in any
the CityofCupertino against
liabilitin,judgmnn,costa and expenses which may inanyway accrue eguwtsuJ City AIR HANDLING UNIT(TO IO.000 CFM) '
in consequence of she growing of this permit.
AIR HANDLING UNIT(OVER ID,IXp CFM)
Signnwre of Applicart Canvactor Data EXIIAUSTHOOD(W/DULT) P
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 10Q0)[I BTU)
Will the applicant or future building occupant store or handle hanndous material HEATING UNIT(OVER IW,"BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)?
11 Yes 11 No VENTILATION FAN(SINGLG RESID)
SU CE DATE
Will theapplicantorfulurcbuilNng acupam use equipmentordevicea whichemit BOILER-COMP(3HP OR 100,000 BTU)
hmurdous air contaminants as defined by the Bay Ares Air Quality Management BOILER-COMP(OVER 10,000 BTU)
Oumico? GJ
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. SEs,
/ 1 have rend the homrdmus manuals re immems uMen Chapter 6.95 of the Cess// {� �����V/\�/��//�//
ift a u;l ingd &Safety Cede,Sections 25505,1 it
and 25534. 1ityto notify
Jut /s
California
Heigh
mnrrends,Sed t,tbat5 is and 25mnsibilitymnoti(ythe ClIY
acu t of quirementa hic a met prior to issuwme of u Certificate of LIC Vy l c"IJ t
Occu /� j A LJ
OOwwicr or m nxd agent �/� Data TOTAL: ISSUED BY:
OFFICE