26462 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
kt'ONTA�:
PERTINO B I.UI -ELECTRICAL PERMIT NO,
APPLICATIONIPERMIT
PLUMBROJECTFIDENTIFIC 26462
qj
BUILDINGIVISION BUILDING NG- I'MECHANICAL
PION
S: SANITARY NO. APPTLICATIONNSSUBMITTALDATE
UNIT# LOT# hyI
PHONE: CONTRACTOR'S NAME: LIC NO:
Is ^, NIC COMIROLN
69 00
ER: f/ L NO: DRF:' : ❑
PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT P UMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DFSCRIPTI
py�Z I lumbyufrnn that l amlicensed underpmvisiomafC pter9(cotmnencingwiih
WOO Section 70001 of Division 3 oflhe Business and Preferment,Code,and my license is in PANELS
FFy U� full force and ellen.
<zzm License
Clar Lic.#—L' ao UPT0200AMPg
Date
rFir,�H Date Ctmtmetor 201.1000 AMPS
Z Ov mARCHITECTS DLCLARA O OVER I"AMPS SQ.FT. OUR AREA S/SQ.PT.
CZ-6 I andeand my plans shall be used as puhlic records, _
�Q
SIGNS ELECTRICAL
g Licensed l'mfessinnal
g
OWNER-BUILDER from the CoATION SPECIAL CIRCUIT/MIS
C
ryX,06F I hereby affirm Net I am exempt from the Contractors License Lew for the
tn3Om following masan(Section 7031.5,Business and ProfessionsCode:Any city orcoumy TEMP.METER OR PoL NST.
sai
1=E:0which requires a permit o construct,alter,improve,demolish.or repair tiny imm ure
W7 pdono its iveuacoast.ouliires Ne applicantfmmch permiuo fileadgned suamut POWER DEVICES DATE
0 that he is licensed pursuanuo Ne pmvisiam of the Connector.License Law(Chapter
o�' 9(commencing with Section 7")of Division 3 of the Business and Professions Cale) SWIMMING POOL FI - VALUATION
yo writer he is exempt herefrom end the basis for the alleged exemption.Any violation of OIf11E1'S-SWITCHES-PIXTIIRLS �•
ZG Sotion707L5bymyapplicantforapermitsuhjotstheePPlicanuoacivilpcnehyof y0a'1
wnot monsoon five hundred dollars($500). NP.W RESIDENTIAL ELELTR S .Pf. V
❑ Lesownemfthepropetty.mmyemployoawith wegesae Neirsolecmmpensmion, Q STORIES TYPECONS'IRUCTION
L will Jt,the work,and Nestrucmre is not inrendedoroffered foreale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who buildsorimproves thereon,and whodoex such workhimselforthrough his OCC.GROUP RES.UNITS
awnemployeee,providMthatsuchimpmvementsamnotimendedmofferedforsale.If,
however,the building orimpowement is sold within one year of completion,the owner. TOTAL:
builder will have the burden of proving that he did net build or improve for purpose of
sale.).
❑ I.asownerofthepmpeny,amexclusivelyconftwingwi licensedcon=tonto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(See 7044,Business said Prefessiom Code)The Connector's
License Lawdcesnm apply tomownerofpmMitywho builds of Improves flummu.and PERMIT ISSUANCE
who cantons for such project with a contrucmt(x)Eceased pursuant to the Conwemrs
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this myon BACK FLOW PROTECT.DEVICE. OUTSIDE
SANITARY Y_N
Owner Dan DRAINS-FLOORROOF, COND. RECEIFI'N
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I herchy of0rm that 1 have a cmificate of conxenuo self-insure,are cendo,me of RECEIPT N
kur rs'Compensmion Insurance oru cenificd copy thcreof(Sec.3800,Lab C)which FIXTURES-PE0.TRAP PARK ME Y N
cove..itOAS-EA.SYSTEM-1 INC.4 OUTLETS R[CEIPI'#
Policy# ` aZ BUILDING DIVISION FEES
CompanyCredited copy is hereby furnished. (EGAS-EA.SYSTEM-OVER 4A) PLANCHECK FEE
Canified cap,is Bled with the city inspection dimmer. GREASEANDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed ribs m,lc,m ifthe permit is fromm hundred dollars(SI(M) SEWER-SANITARY-STORM EA.200FT. ENERGY FEF.
or lees.)
I cenify that in the performance tithe work for which this permit is issued,l shall WATER HEATER W/VF.Nf/ELF.C11
not employ tiny peoan in any manner so as to become subject to the WorkersPAID
Z Compensation Lawsof Celifomin. Date WATERSYSTEM/TREATING Date Receipt#
O O Applicant
NOT'ICE'I'0APPLICANT:It,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
Hbecome subject to the Worker's Compensation previsions of the labor Code,you must
ai , forthwith comply with such previsions or this Permit shall be domed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z I hereby affirm that there is a construction lending agency far the performance of
V O da.work for which this Permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
��--hh LrnJcrs Name
U.
t—' lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) I cenify that I have read this application end stem that the above information is
kk1 comet. In euro comply yen y g MECHANICAL FEE
agree py wileyam and representatives
upon m PERMITISSUANCE
heeding construction,and hereby uuthariu r p seemutives of thisciry m enter upon the CONSTRUCTION TAX
V7 abnv(We)iionee Propertyforinspection purposes. ALTER ORApD TOMECI I. -
.^. (We)ogres to save,indemnify wt,keep hurml/exq�s�th/e/C/it//�y�cof Cupertino against
liabilities jcllobilities d�'e d expcnsesrrout. oyeL/� mee8 sl City AIR HANDLING UNIT CTO IO.gXI CPM)
f renting of thio pertnit.
AIR HANDLING MIT(OVER 10,000 CFM)
Signmum of Applicent/Connuctor Dam EXHAUSTHOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001 BTU) Dan Receipt
Willtheappimant orfuture building ocap.,amrc or handle mamma malarial HEATING UNIT(OVER 100,00D BTU) TOTAL:
r defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health end Safety
Cala Section 25532(e)?
11 Yes ❑No VENTILATION FAN(SINGLE RESID)
) CaE I A'I:'E
Will NmwmBOILER-COMP(311P OR 100,000 BTU) ISSIAN(fy
eupplicuorfurehuildingoccupenlu
equipmentordevioswhich emit ti yJJ
amolms it contominiu s as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
imricR ,JUN 1 19JA
p
CI Y. 0N NEW RESIDENTIAL MECH. SQ.FT.
1 have tad the hazardous materials requirements under Chapter 6.95 of the CITY Ur v ``PP
Celifomia I lealth&Safety Cade,Sections 25505,25533 end 25534. I undemend Nm W rtk
-,he building does tea currently have a muni,that it is my rcsponsibiliry to notify Ne
occupant of the requirement which must be,met prior to issuance of a Certificate of
Occupancy.
Owner m as lmhoul agent Date TOTAL: ISSUED BY:
OFFICE