26003 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "In PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 26003
BUILDING.PROJECT IDEN'HFICATION
BUILDING ADD
RESS: - rx.a)C - SANITARY NO. ADPL^�%��MfITAL DATE
/070M (/0,J/A UNIT# LOT#
OW ERS ME: PHONE: CONTRACT9R'S NAME: LIC NO: NIC CONTROL.#
ZS O wr uo11 oQ
AR HITEC NGI LIC NO: ADD SS: El
CONTACT: PHONE: .0 60
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
J ere SSG 7 bol o PERMIT ISSUANCE BLDG ELECT P U MECH
El 1:1 BLDG
LICENSED CONTRACfORSDECLARATION APPLIANCE$-RESIDENTIAL LOB DESCRIPTION
p-.z
thereby eff Division
3 ofthnsedunw,andvisionsofCTapter9nd(commencing se with
00 Section]0007 of Division 3 of the Business and Professio Code,and my license is in pgNE1$ ,
a 1C; full Locrusceand Ufe q � ♦ l ,ate/
Fz❑ License Ila-s �_ Lic.q n IIP T0200AMPS \(�f���{a�� ��\`__l!1+
vary Dam Contractor 20I-1000 AMPS
zON� ARCHITECTS DE -ATI OVER IMAMPS
SQ.PI'.FLOORAREA $/SQ.FT.
O z-0 I understood my plans shell be used as pu tic records.
Pyt .N SIGNS ELECTRICAL
g ...41 Licensed Professional
ccg OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOii FU 1 hereby-111—that I a
m exempt from the Contractors License Law far the
W✓0 ma fallowing reason.(Section 7031.5.Business and professions Code:Any city or county TEMP.METER OR POLE MST.
�n which requires a permit to construct,alter,improve,demolish,or repair any structure
POWER DEVICES
pdorm its issuance,also requires the applicant fmsuchpmothr,file a signed stammenl
0.<O thm he is licensed pursuant to the provisions of the Cotnmctor's License Lew(Chapter 0E' 9(commenctng with Section]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iiW((_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI
} Section 7031.5 by any applicant for a ronit subjects the applicant toe civil penalty of
Qns
[more then fere hundred dollars($5W). NEW RESIDENTIAL EL ISQ.FT. STORIES TYPE CONSTRUCTION
W C ❑ 1,asowneroftheproperty,ormyemployeeswi0wagesastheirsolecompensauon,
y will do the work,and the structure is not intendedoroffered for sale(Sec.7044,Basinesspt
and Pmfessions Code:The Contractor's License Law does not apply to an owner of I _ Y i
property who builds orimproves thereon,andwhodoes such workhimselforduoughhis
own employces,pmvided thatsuchiniprovemmtsarenotintendedoroffeted mrsale.If, OCC.GROUP REB.UNITS
however,the buildinger improvement is sold within oneyearofcompletion,theowner- ,
builder will have the burden of proving that he did not build or improve for purpose of _
sale.).
[11,as ownerofthepropedy,am exclusivelycontracting with licensed contrectersto QTY] PLUMBING PERMIT FEE FLOOD ZONE APN
nslruct the project(Sea.7044,Business and Pmfesslaos Codc:)The Contractor's
License Law dcesnotepply manownerofproperty whobuildsorimproves thereon,end PERMIT ISSUANCE
who contracts forsuchprojects withacommcmrts)licensed pursuant to the Contractor's ALTER (FA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this renson BACK FLOW PROTECT.DEVICE OUT OE E
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
i ❑ therebyafflrmthatlhaveacenificateof cons entmealf-insure,oracanifrcareof FIXTURES-PER TRAP RECEIPT#
Immuneor
Warkers'Compensation Immune a certified copy thereof OSec.3800,Lab CJ which PARK FEE Y N
Poet cY�l em�lLay�e^under thiaw Civ r GAS-EA.SYSTP.M-I INC.40UTLETS BUILDING DIVISION FEES
Policy# GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
3a Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200FU ENERGY FEE
or less)
I certify that tithe in a any
woofer so as for whichthisiubjecpermit o issued,I shallWorkers' WATER HEATER WNENT/ELECIR
not employ any person in any rummer so az to become subject to the Workers' PAID
Z Compensation laws of Celifomin. Date WATER SYSTEM/IRFATING Data Receipt#
NOTICE
a t
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
V] become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions.,,his permit shall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that there is a construction lending agency for me performance of
the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
(A Lender's Name - PLUMBING FEE
0 F Lender's Address QTY, MECHANICAL PERMIT FEE
U I certify that I have read this application and slide that the above information is MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE
Uj buildingeonso-uctlon,and hereby authorize represenmtivesofthis city to timer upon the CONSTRUCTION TAX
U 'z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
lixbtlitics,judgments,costs andex,moves which may many way arecrueagainatsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence oflhe rnming fthis permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si tore A Iican4Comm tm EXHAUST HOOD(W/OUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant arum or handle hazardous materiel HEATING UNIT(OVER 1W,IXq BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health end Safety
Cade.Section 25532(x)? VENTTLATIO MCLEEESI
❑Ym ❑No
ISSUANCE DATE
Will theapPlicentorfuwrebuildingnccupantuseequipmentnrdevices whichemit BOILER- OMP(3HP OR 100,0008 )
havardous air contaminants as defined by the Bey Area Air Quality Management I
Diso-tc0 BOIL -COMP(OVERI
❑Yes ❑No NEW ESIDENTIALPAFD
I have read he hazardous.medals requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that VAN 11 1996
if the building does not currently have a tenant,that it is my responsibility to notify the
Ocupant mite re,timemerds which most b,met prior to issuance of n Certificate of
ccupancy. �S',.
Owner or authorized agent Date TOTAL: ISSUED BY:
OF