26810 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO d�H,DIN,-6LuIC MICAS, PERMIT NO.
APPLICATIONIPERMIT PING FROG CT IDENTIFICATION
2 6 8 1 C
— BUILDING DIVISION BUILDING PROJEI;'1'IDESI'14'ICAq'ION
BUILDING ADDRESSes SANITARY NO. AP^PLICATIONSUBMRTALDAT
(. V�J Y 1I (-JyLil1�TX LOT
OW :RS NAME Ps1�10NE: cow NA ^— LIC NO: NIU ( CONTROLM
• ABC II I'ECT/IiNGINRER: LIC NO ADDRESS: ❑
CON"
ACT:
PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
PERMIT ISSUANCE
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensed under p ( gwith JOB DESCRIPTION
O e'Z Y u prd llmfin imis Code,
commencm
,00 fadoracmdefDivismn7ofine Bu.incss and Vrofession Code,and my license is in ppryBL$
,�� ran rmee a-e erred.
La.,GY] License Class Lica UP T0200 AMPS
L, Data Contractor 201-]Bob AMPS
7ONL ARCHITECTS DECLARATION OVER 1000 AMPS I SQ.FT.FLOOR AREA S/SQ.FT
CZ-0 IundcmanJ my plans shell be usednpublic records. 1 L B
l-ti E' SIGNS ELECTRICAL
Qx�,, licenced Pro[cssbinvl
OWNER-BUILDER I am BUILD ER OL CContra ON SPECIALCIRCUITTMISC.
XOaU 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W LLOy folbwing rcawn(Seaion]03 L5.Business and l4oPossions Cade:Any city or counry TEMP.METER OR POLE INST.
F which regolrns a permit to anstruct,.lmT,improve,demolish.or repair any su m ora CO! q
EyW}� prionoin issuance,a)somquires the applicant!arsuch petmitm Gleasigned.statement POWER DEVICES E y
W Y C O that he is licensed pursuant o the provision ec
of the Conntors License Law(Chapter _
c. 9(Commencing with Section 7001 of Division 3 ofthe Business and Professions Caere) SWIMMING POOL ELECTRIC VALUATI(3N1
W_y or that he is cxcmptherefrom and the basis fonhe alleged exemption.Any violation or OIITLEI'S-SWITCHF,S-PIXTURGS
FZY
Section 7031.5 by any applicant for a Permit subjects the applicanno a civi l penalty of
SS¢p not more than rive hundred dollars($5W). NEW RESIDENTIAL ELECfR SQ.Ff.
CIL. ❑ l,usowncrofthepropony.ormyemployceswithwagesaatheirwiecompcnsmion, STORIES TYPE CONSTRUCTIOI
a3— will do the work,and the structure is notimcndell oroffcred forxale(Set.70,14.Business
and Perfessionn Code:The Contractors License Law does not apply to an owner of
,mpary who builds ar improves thereon and whodoessuch work himselforthrough his
owramployacs,pnrvideJ thntsuch improvements are notimcndeduroffemdforsale.If, OCG GROUP RFS.UNITS
however,the building or improvement is sold within one ycarofcompletion,the owner- TOTAL
builder will have the burden of pmving that he did not build or improve for purpose of
owncrofthe Propco4,4,Business
end Preactingwithde:)Tdconractorsto QTY. PLUMBING PERMIT FEE FTOOD ZONE ANN
cont a the ptojea(Sec.]BW,Bminess anA Professions Cade:)The Contractors
License_awdecs not apply toanownerofpropenywho builds or improves thereon.and PERMIT ISSUANCE
whonamacls for such projects with acommareads)licensed pursuant to the Contractors ALTER- ( )
License Law. DRAIN D FEE SUMMARY
❑ 1 am exempt under Scc. ,R&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE PEES
Owner Date
SANITARY Y N
DRAINS-FLOOR.ROOF,AREA,COND. RECEIPTp
• WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihemby affirm thmlhave acmificam of consent mself-insure.mseeni6catenf
Warkers Comptsm
erioor
n Insurance a ramficd cop,men (Sea.3800,Lab C.)which FIXTURES-PER TRAP RECGIPfa
PARK FEEcoveY N
n all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT a
Policy% BUILDING DIVISION FEES
Company
❑ Ccnided copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is fled with the city inspection division. GREASEANDUSIRI,WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS HE
INSURANCE
(Thissenion need not he completed dire permit is forone handrnl dollars SIBB) SEWER-SANITARY-STORM EA.2010FT. ENERGYFEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
nal employ any Perla- to any manner su a to biome subject to the Workers' PAID
z CAo Ipenatm
mn Lowsof Culifomia. Date WATER SYSTEM/TREATING Dam Receipts
C) NOTICE'I'OAPPLICANT:IIaftermaking this Cerificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
F (n become subpar to the Worker's Compensation provision of the Labor Cade,you must
� ; forthwith comply withxuch IF...War,or this permitshall be deemed revoked BUILDING FEE
p„ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) 2 ]hereby affirm that them is a construction lending agency for the performance of
V O me work far wheel this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is
F0. cmtcct.I ogres,to comply with all city and county ordinances and.state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby aummdu repmttntatives of Nis city tocater upon the
V 2 above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCTIONTAX
(We)agree ,,save,indemnify and keep harmers the City of Cupertino against
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
Rlcnccofthegrantingof this pemtit. AIR HANDLING UNIT(OVER ln,"CPM)
te.✓ .ofA ma"A"'.racmr Date EXHAUST HOOD(W/UUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100fM BTU) Date Receipts
Will the applicant or future building occupant.store or handle hamrdou,material
as defined by the Cupertino Municipal Cade,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,00)BTU) IOTA .
Codc.Stratton 25532(a)'I
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will meapplicunmrfmum M1uildingacupantnuegoipmrnt ordevic<s which emit
BOILER-COMP QHPOR 100AW BTU) ISSUANCE DATE
bmurdous air contumimnu as defined by me Bay Area Air Quality Management BOILER-COMP(OVER 1fisk"BTU)
Districts ❑ pq
Yes ❑No NGW RESIDENTIAL MF.CiI. SQ.FT. {�'
I have revel the hummus materials eequirettrcnts umber Chapter 6.95 of the _r ^
Califomia Health&Safety Code.Sections 25505,25533 and 25534.1 undestombthst J1/4 N%9 �O($
it etm requirements he building does not cmnently nave o tenant.mat it is my m1ponsihility to-miry the ,7 JA
cupaof the requiremes which must be met prior to issuance of a Cerlficme of Ut- 'I 7
Owner or amhomcd agent Dolea J
L: ISSUED BY:
OFFIC