26646 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
]THEIAI�Sf .-LLE,(, I'RI AI.
PiG-Me'ICAL
OUILDING DIVISION APPLICATION/PERMIT BUILDINGPROIELTIDENrIEICA1'[ON
PERMIT NO,
26646
BUILDING ADDRESS: it
$ANI'FARY NO.
APPLICATION SUBMIT]AL GATTH
UNIT X LOT I
s{
lJ 1.
OWNER A F.: PHONE.:
CO li: LIC NO:
Q A4
NIC
❑
CONTROL p
RCI INEER: LIC NO:
ADD
CONTACT: PHONE:
QrY. ELECTRIC PERM IT FEE
BUIhDING PERMIT INPO
BLDG ELECT P UM MECH
PERMIT ISSUANCE
-
❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm That I am licensed under provisions nfChupler 9 (commencing with
APPLIANCES -RESIDENTIAL
IUB DES 11'IION .
PANELS
UP T0210AMPti
Sec1loa 7000)of Divi m3ot(be Blon.,esand Professions de, and my license is in
full toles lode c OI
I-icense la Lic.R
Ilulc Con¢aetor
ARCIII'I'ECI-S DECLARATION
I undc,tand my p arts shall be used as public records.
201 - II111U AMPS
OVER I"AMPS
SQ. Fr. ILOOR AREA
_
5/SQ.IT.
SIGNS ELECTRICAL
- •
Licensed l'mlcssiomJ
OWNER-BUILD17R DECLARATION
SPECIALCIRCUII'/M
n
T
- 1 hereby affirm that 1 am exempt from the Cnmmnor's License haw for the
following reason.(Section 7031.5, Imsl aumad Professions Cotle: Any cblyor,mmly
II — x�a
rG,�i
TEMP. METEN MLR INST. nn
which ...vires a pemtil m wnnmct, ehcq improve, JemolisM1, or repair uny aWtture
priorm it issuance, also requires the epplicamfor such Permit to rile aligned statement
POWER D ICES J
That M1e is licensed parsuanlm the pmvidla, of The Contractor's License Law (Chapter
y[commeneingwilh Section 9[xul)nf DivisianJoftbe Bnslneaannd Proressions Cndc)
SWIMMING M01. P.LEC111C
AIAATIUN
OUTLETS -$WITCHES -10
-
or That he is exempt mention. ad the basis for The alleged exemption._ Any violation at
Section 7031.5 by any applicant for a pemsit subjects The applicant To a civil penalty of
Zen more hour five handled della,'(55011).,
❑ I,asnwnerortheproperty.mmyemployeaswiihwagesmikeirsobecampedsaiov,
NEWRISIDENTIALELECTR_SQ.Pf.
ST IES
TYRE CONSTRUCI'ION
will do the work,andthesmucmre is not intended omffered for sale(Sro. 1044, Business
and Professions Code: The O mrumors License Law does not apply to an owner of
property who buitkor int Intoe..thereon, and who dopa men walk himself nr thnmghbbe
own employees, pmvidal Lha such impmvcments me nm intenAed ur offend for sole. If.
OCC. GROUP
RHS. UNITS
TOTAL:
however, the buildingor improvement is sold within one yearofco depletion. the owner-
builder will have the burden of proving Elm he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
robe.).
❑ I. as ownerofthe property, amexcladvelycontructing with lbcensede"mmeton to
FLOODZONE
APN
nulmot Its project (gee 7044. Business and professions Cale) The Cmaowlms
I.icenselatw JoesnautpPlytoannwnenofprupenywhab::ildsnrintpmvexibereon,und
PERMIT ISSUANCE
whocontruls fur.such pmjeets with a contractor(s) luenxdpunuent tothe Contractor's
License Law.
ALTER (IA)
FEE SUMMARY
❑ 1 am exmnpt under $ec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE IDT. I' ; .S
Owner
DRAINS - FLOOR, ROOF,ARFA,COND.
SANI'T'ARY Y
RF.CF.T"
WORKMAN COFIPENSATION DECLARATION
❑ Ihmeby affirm lM1:nlhnveucedificme of consenno self -insure, nrucertifcam of
Workers'Compensnti"n Insurance"r acertifed copy thereof(Sec. JB00,lah CJ which
SCHOOL TAX YN
RECIi1P1'K
f VIXTUREST-PER TRAP
!
PARK FEE Y N
- EA. SYSTEM -I INC. 0 OfIT1.I:1'S
overs all employee's under dais permit.GA$
Policy p
RECEIPT N
BUILDING DIVISION FEIiS
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK PEE
❑ CodifiCooed copy is hereby famished.
GITEA$H/INDUSI'RL WASTE IN03RCI!PTOR
GRADING HE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FI'.
ENERGY FEE
(Thisxeaicn neednot be completed ifine permit is forone hundred dollars (j100)
orless.)
WATER HEATER WNFNTELECTR
I codify that in the perfomance of the work for which this permit is issued, l shall
not employ any person in my manner so as to become subject to the Workers
PAID
CanTpensalimT Lows of Culifomia Date
Applicant
T
WATER SYSTEM/REATING
m
DaRweiplM
NOTICE TO APPLICANT: If. after making this Cenificete of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. you most
NEW RESIDENTIAL PLMII. SQ, FT.
-
TOTAL:
foohwhb comply will, -ch Tro,kiolao, la, permit shall be deamed revoked.
BUILDING PEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a conam6tion lending agency [or the performance of
I'
ELECTRIC PER
the walk for which this .it is issued Nec. 3097, Civ. C.)f
Irtndres Name
Lenders Address
QTY. MECHANICAL PERMIT FF.E
PLUMBING FEE �T
I cenify that l have real this uppbicuum and thme It., the above infmmmom is
mecl. Iagrcewcnmpy with all city and county ordinances unJ slate laws rtmingm
PERMIT ISSUANCE
MECHANICAL FEE
balldbngconstruction,and here by ecresoieummea mtivesof Ihi><ity to entttupon the
aMry p inspection purposes. -
ALTER ON ADD TO MSCI I.
CONSTRUCTION TAX
(We) ;lone save, indemnify
(We) ogle to,co Indemnify and keep harmless Ih•e City of Cupedlna
—
costs idagainst
City
rne,emne,pra andexpemeawhichmayinanyweyacttueagvna said City
AIR HANDLING UNIT (TO 10,0ooCFAt)
inc.larm
cnnsequenee of the grueling of this permit.
- --
AIN HANDLING UNIT(OVER CPM)
Signature of Applicem/Cormaclor Date
EXHAUST IFOOD (W Ml
PAID
HEATING UN;PffO 100 oato FIT U)
HAZARDOUS MATERIALS DISCLOSURE
Lure Receipt If
Will the applicant or future building occupant more or handle hazmdous material
as defined by lM1e Cupedinn Monici ICode Chapter 9.12. and The Health and Safely
HEATIN NIT(OVER 100,1100 BTU)
T'1'
Calc, Section 25532(u)4 ,, /�°
11 Yes IW_ Vo .- _
VENT ATION PAN (SINGLE RESID7 s
Will the npplicam ortumre Fail dingoccupem useequipmem nrdevicu whichemiT
BD ER-COMP('BP OR 100,000 BTU)
ISSUANCE DATE
B ICER -COMP (OVF8 IBO,COP BTU)
'hamrdous eI, em m aranls us def,�rd by the Bay,Ares Air Quality Management
D'uWel'! I r /
_
12 yrs
1 have rad the hamrAous materials requirement. under Chapter 6.95 of the
p�
P AID
NEW R ESIDENTIAL MSCI I. SQ. Fr,
CalifoJH�IthSafely Curl, Sections 25505. M533 and 25534. 1 undermld that®fy�if
the hnnT<urrcmly buveemnem,Ihgl it isp,y respon.Jbility To notify the
AUG
tmust c et prior in issuanceora Cenificam ofOcc
V 0cupui.
CII Y II /
ISSUED BY: VI 1 d
n amhous,cl agent Dule
TOTAL:
vrrlwt