26634 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I G- N'I'CA ' PIiRMIT NO.CITY OF CUPERTINO PLUMBING MEIICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDEN11FICAIIIN
26634 C63LBUILDING I— SANITARY NO. APPLICATION SU
BMITTAL DATI,
UNiLOT# G- /V
OWNERS NAME: PHONE: A S NAMI?: O:
—!
NIC c.'ON"fHOL#
AHCIIIIIiCI'/13NGINIiIiH: LIC NO: )
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PLUG ELECT PLUMB MECII
PERMHISSUANCE 0
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
OCZ I herebyaffifm tom pr
l am licrn,odmide, ovisions nfChapmr 9(commencing with mak . __ IWU�E: HII f10�UV
[100 Smdinn]000)of Divisinn3ofbr
PANELS
C fullforceandcffe 4100- � UPTO 20AMPS u
4F Z W I's"o a Class Loc.In
y 66Ua¢ Contracmr 201-I"AMPS
vs 5 FT.FLOOR AREA $/SQ.FI'.
,ON2, ARCFIITELTS DECLARATION SQ.
1000AMPS Q
O Z—0 I understand my plum.hall be used m public accords.
F,w F I SIGNS ELECTRICAL
Z�tedai<
H Licensed Professional OWNER-BUILDER DECLARATION SPECIALCIRCUII'/MISC
P.0 I hereby affirm that 1 um exempt from the Contractor's License Law for the +` t
t+140or following mason,(Section]031.5,Business and Profession.Code:Any city or county TEMP.METER OR POLE INST.
which acquires a permit to construct,alar,improve,demolish,or repair any soucmre I t 0 V
5 }� Prior to its issuance,also real the applicant for such pemtilto file a signed smm
ment POWER DEVICES 74
WW<0 that he is licensed pursuant the provisions of the Contractors License Law(Chapter SWIMMING IsOOL T:LECfRIC
daoPf 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) _ VAI: TION
IyKj My or that he is exempt thereGmm and the basis for the alleged exemption.Any violationof OIIILEfS-SWITCHES-FI%TURES -
F Z Q, Section 7031.5 by any applicant for a pertnn subjects the applicanuo a civil penalty of
G not mom than five hundred dollars($SW). NEW RESIDIiNT1AI.ELECIR SQ.FT.
X m El Las owner oflhe FmNrty,or my employees with wages as their sole compensation, STORIES TYPECONSTRUCI'ION
ywill Jo Ilio work,and the shtcwre is not intended or offered for sale(Sec.]f144,B adness
and Professions Cast'1'he Contractor s License Law does not apply to an owner of
property who builds or improves thereov,and wM10 dses such work himself onlwugM1 bis
employees.providedlhm such improvcmen¢arenotimendeduroffercni Tarsale.IL OCC GROUP RES.UNI IS
however,the building or improvement is sold within one year of completion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
`ole')' QTY. PLUMBING PERMIT FEE Fl ZONE APN
❑ I.awwncrofnc�property.umexclusively contracting with licenudconoazton m
construct the project(Sec.71144.Business and Professions Code:)The Contractor's
Liana Lawdess not apply to on ownerofpropeny whobuildsor improves therescri PERMIT ISSUANCE
who aommms forsuch projects with accomerm(s)licensed prounnuo the Contractor's
license Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason OIITSI DI:19iC5
BACK FLOW PROTECT.DEVICE SANITARY Y—N
—
Owner Da¢ DRAINS-FhpOR.HOOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm thud hwcaanificam of conunuo self-insure,ma ttrdfica¢of FIXTURES-PER TRAP RECEIPT
Workers Compensation Insurance or a mNfied copy thereof(Sm.3800.Lab C)which PARK FEE Y N
covers all employees under this permit. GAS-EA.SYSTEM-]INC.4 OITTLEfS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSI EM-OVER 4(EA) PLANCHECK FEE
❑ Certified crony is hereby l'umishcd.
❑ Certified copy is tiled with the city inspection Jiviximrt GREASMNUUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This uOinarned not bemmpleted iHhc pconit is(mrnne hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icmify that in the performance of the work for which this permit is issucd,Ishall WATER HEATER W/VFNTryLECfR
not employ any person in any manner so as m become subject to the Workers' PAID
Gmtpensation Laws of Calilitmia. Date WATER SYSTEMNREATING Dom Reccipt#
O z Applicum
z � NOI'ICE.TOAPPLICANtir,after makingtMsCenificutcofExemption,y.ashould NEW RESIDENTIALPLMB.—SQ.Irl. 1'0'1'AL:
I"' y becnmesubjecuo the Worker's Crompensow.provisions of he labor Code,you must
0 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING IEE
LL] ^ SEISMIC FEE
4 Q CONSTRUCTION LENDING AGENCY
U1 hereby affirm that them is a construction lending agency for the performance of O
the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
lender's Name PLUMBING FTE
C) F Leonia',Address QTY. MECHANICAL PERMIT FEE
J 1 cem y that I have read This application and state That the above information is MECHANICAL FEE
>` correct.l agree locomply with all city ondcouony ordinances and state lawsrehar,to PERMIT'ISSUANCE
sir N buildingcorwoucrion,andhersby anthoroze representatives ofihis city roamer upon the CONSTRUCTION TAX
Vz above-mentioned property lot inspection purposes. ALTER OR ADD TO MECH.
(We ago« save,indemnify and I em the City of penino egainr
liabilities,ju na,costsmM expcnuswli It yinanywayn a against said City AIR HANDLING UNIT(TO 10,000 CFM)
In s qts m ranting of this pcpri
AIR HANDLING UNIT(OVER 10,000 CFM)
naumof Applicant/Cnnvncto Dat EXHAUSTHOOD(W/DUCI
pn1D
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI'['('1'0 R 0,000 BTU) Date Receipt#
Willlhe epplicanl or furore building occupant sTom m handle harmonious material HEATING ON]'1'(OVER 100.000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)] VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicator future huilding«cupantuxequipmemordevices which emit BOILER-COMP(311P OR 100d)(O BTU)
lei
>amormous air contaminants as defined by the Bay Arca Air Quality Management BOILER HX,000 BTU)
ixtrietp 6
❑Yea ❑No NEW RF:SNIiN'I'IAI.MI7Ct1. SQ.PI'.
I have read the hasiodous materials requirememx under Chapter 6.95 of the �JU� 2 8
Culifromla Hearth,& 25
Safety Code,Sections 50 34
5.25533 and 255 . 1 understand that 1994
if the building does not currently have a tension,that it is my responsibility to notify the X77
occupant of the requ dements which must be met prior to issuance of a Certificate of 611 Ur f
,Occupancy.
Owner or amhomcd ,at Duro TOTAL: ISSUED BY:
OFFICE