26197 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ul'"ll R7-ELECTft PERMIT NO.
R ILDING_DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C (��.
N - °BUILDING PROJECT IDENTIFICATION , v J
BUILDING ADDRES
rrS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z//
b £ DNIT# LOT#
O QRS NAME: PHONE: CONTRA�T N LIC NO:
NC N/C CONTROL#
%RCHI I CUT/EN I EE LIC NO: ADDR ❑
CONTACT:; PHONE: X'�A'V` ' S ti%a'a 6'r i V 3 &a -t i•i$a,b 1'BUILDING PERMIT INTO-' -
Qa3kC im� sI4a e; FEss�
�-fQ BLDG ELECT PLUMB MECH
1 , l 1 PERMIT ISSUANCE
LI ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GYZ thereby afiml that l am licensed underpmvaionpsofariler9(commenting with ]OB DESCRII'fION
HOCSection 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS AVIK
RbEfull force and effect. �a
Z,W Womr
LLemm Cl ^ Lie.# 7 ` UP T0200 AMPS
yea Date Ciraactor 201-1000 AMPS
t-"ON ARCHITECT'SDE T SQ.FT.FLOOR AREA $/SQ.FT.
ZOy OVER RRIO AMPS
land my plans shall be used as public records.
SIGNS ELECTRICAL
<—=
Licensed Professional
L� Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�a(Ow, I heavily affirm that I an exempt from the Contractor's License Law for the
W 30..y following reasno.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O Q which requires improve,demolish,humor In construct,alley,impdemolish,or repair any structure
W¢� prior to its issuance,also requires the applicant for such permit m fileaslgned statement POWER DEVICES
W a p O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
4 n,o Fe 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) VALUATION
or that he isexempl therefrommndthe basis for the alleged exemption.Anyviolationof OUTLETS-SWITCHES-FIXTURES
FZG Section 9031.5 by any app1mot for apermit subjectstheopplicanne a civil penalty of
� � �ol I.as wn rofhepro ny,odollarmyem). NEW RESIDENTIAL ELECfR _SQ.FP. STORIES TYPE CONSTRUCTION '
❑ Las nwneroHhepmpertg isnoti pended withwegesasthei(Sec.compensation,
a will dolhowons and the he Contractor
is Licence
Law doesed of apply
9044,Boniness
and Professions Code:The Contractor's License Law does not apply to an owner of
pmpertywhobuildsorimprovesthereo,andwhodcessuchworkhimselforthmughhis 01
ever,the
h eve,provided that a,mcch improvements are nmyea ldcdorplefio d fmsale.If,
OCC.GROUP RES.UNITS
however,ill have
l the burden of emem is that
lie idn nt build o(wprove for t purpose
f L
sale).r will hove the burden of proving that he did not M1uiIJ or improve for phryose of
sale).
as ownernf the ro n ,em exclusive! conunohn with hcensedcontractoero QTY VY;Y PLUMBING PERMIT.r 4 pdph3PRE FLOOD ZONE APN
P PeY Y 6 Aar .o
construct the project(Sec.7N4,Business and Professions Coda)Tha Convenors v
License Lawdoes not apply to anownerofpmpen,who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with acontmmmgs)licensed pursuant m the Contractor's ALTER-DRAIN&VENC-WATER CA7 License Law. (' FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE } OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT#
DRAINS'-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION ofeu DECLARATION SCHOOL TAX Y N
❑ caaChereby
.an..that lhave acertifiame ofwmem to self-insure,oracertificete of RBCBIPT#
FIXTURES-PER TRAP
Workere'Compensetion lnsurnnce ermcertifieA copy therwf(Sec.3g00.LnbCJ which PARK FEB YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYS'T'EM-OVER 4(EA) PLANCHECK FEE
❑ Candied copy is heaby famished.
❑ Candied copy is filed with the city inspection division. GRGSWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS PEE
COMPENSATION INSURANCE
(This section neWnol be completed ifthepernit is far one hundred dmllere($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
orlem.)
I cmify that in the perfomlance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ,any person in any moaner so as to become subject to the Workers' PAID
Compensation LawsmCalifomia. Date _ WATER SYSTEM/TREATING Data Receipt#
O z Applicant
Z NOTICE TO APPLICANT:IL a far making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff.
t+ V] become smbject w the Wotkds Comparison..punisaiem of the Lubar Code,you hat
Ia^ forthwith comply with such provisions or this permit shell be deemed revoked. BUILDING FEE
W (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of TOTAL ELECTRIC FEE
0 the work for which this permit is issued(Sec 3099 Cis.C)
�+ Lender.Name q$P "F't
W t-� 'x` kS h E i . PLUMBING FEE
Lenders Address Q-FY.'d «MFCI{ANICAI PPRM17j p y;," PEE-n
C U I really that I have read this application and mate that the above information is am w a "'°" s `
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representalovesmfthis city m th
morupinc
H CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupensts id against
liabilities,judgmems,corns and expem chaiichmay in any way accrue against said City AIR HANDLING UNiI'(TO 10.000 CFM)
in crew fut granting of ermik C AIR HANDLING UNIT(OVER 10,000 CFM)
- — e EXHAUST 400D( DUCTSICionoc PAID `
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1000,001)BTU) 'Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1
❑Yes 13 No VENTILATION FAN(SINGLE REBID)
Will the uppl irunl or fuwre buildlog occupant use equipmaomrdovlcee which emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
m mus air contaminants as defined by the Bay Area Air Quality Management BOILER 100,000 BTU) fj
�i.wety .41
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I i have read the hazardous Sections requirements under Chapter understand
of the �q•l O�
California building
do s Safety Code,Sections 25505,25533 and 25534. I understand that
litheoccupantof gdoequiremnts with a.,correctly ust In, thatins mymanceibfa Certo nficat the
ccupan of the requirements which must be met prior m Issmence at'a Certificate of
Occupancy.
Owneroraulhodzedagent - Date TOTAL: ISSUED BY: N�
OFFICE