26819 (2) eqpjAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITS(()F CUPERTINO BUILVINU -- PERMIT NO.
APPLICATION/PERMIT PING RING-MEDENTIFIC 26819
- BUILDING DIVISION BUILDING PROTF.C'1'IDf;NTIPICAT'ION
BUILDING ADDRESS: �I�,'E �� SANITARYNO. APPLICATION SUBMITTAL DATE
SVA~%)%) I UNIT# LOT#
OWNERS NAME: PHONE: ACYS ME: _ — LIC NO:
O NIC CONTROL#
RCHITF,CTIENGINEER: LIC NO: RESS
✓Ca s
CONTACT: PHONE: QTy. ELECPRIC PERMIT FEE BUILDING PERMIT INFO
BL�DrG ELECT PLIJMN y CH
PERMIT ISSUANCE J
LICENSED CONTRACTOR'S DECLARATION pppL1ANCES-RESIDENTIAL T JOB D65CRIP1'ION
nwz Iherebyaffitm that Into licensedunder provisim,.02Tapmr9(Commencing with
u�oq4-,u Sectioneandmf Division of the Business and Professions Code,and my license ism pprypyg
y�U W full Lice
rce and cffm.
W License Cass Lick UP TO 20d AMPS
y6y Convaztor 201-100DAMPS
F� ARCHITF,CTS DECLARATION S FLOOR E/SQ.FT.
OVER IOW AMPS 4/OR
O Z_ I undersand my plans shell h used as public records.
4
; SIGNS ELECTRICAL Y f,, Licensed I'olessional
C I=< OWNER-BUILDER DECLARATIONSPECIAL CIRCUUNISC.
X,W U 1 hereby nBlnn that 1 am exempt from the Contractor's License Law for the
w a LL. following reason.(Section 7031.5,Business and Professions Code:Any city or counry TEMP.METER OR POLE INST. O�
k-.yam which nquhes a permit to ecoolo m,alter,improve,demolish,cr repair any sh<ture
,W>-;: prior to its issuance,also requires the applicant for such pert to file a signed sometimes, POWER DEVICES \
wpp0z thm he is licenxd pursuant the Provisions of the Contractor's License Lew(Chapter
dkoLL 9(commencing with Section 7")of Division 3 ofthe Business and Professioae Code) SWIMMING POOL ELECTRIC VALUATION
Wn, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
FZp Section 0031.5 by any applicant for a permit subjects the applicant OUTLETS a civil penalty of SWITCHES-FIXTURES t
_ not marc Than rive hundred dollars(E51M). A/•iM{i/i
aF I,as nwncrnfthe aro 'atop y g pensation, NEW RESIDENTIAL ELECTR S .ET.
� ❑ I acauerm oeeswpbwaears thei(See.Com Q STORIES TYPE CONSTRUCTION
n3— will dothewonsCde: shudureisntrinmicense Law ffeared
ran apply to an,edl,Business
and Professions Code:The Contractor License Law does not apply if an,owner of
own
wheb,provi improveschemun, ementam east inane khimselfm through his
can emploebuildovlded pr ve impmvementhin ne earof ompletered for sotto r- OCC.GROUP RES.UNITS
however,thebuildingnrimprovemem issold withinone year o improve
thrower- l
builder will have the burdrn of proving that he did trot build or improve for purpose of
❑ Las he m)jfthe See.701,Business
ad Ponacf,ione; h licensed convattorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE gpry
construct the pnjxt(sec. sm,Basincas and ywho bidlc Coda)Tire Gmhemr's
License Law dace not apPly rornowaerofmoany whoseddsorimpro the thereon.mmd PERMIT ISSUANCE
who mmrtenfor such Pmjecrs with a<ommmor($)licensed pursuanuo the Contractors
hmnne Law. ALTER WATER(Eq)
FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACKFLOW PROTECT'.DEV ICE OUT$IUG FEES
SANITARY YN
Owner Dae DRAINS-FLUOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPEN$gT10NDECLARATION SCHOOLTAX YN
❑ Ibarcbyaffirmthat
Immarnccnifiwmofconxnuoxl(insure,or na C.))which FIXTURE$-PER TRAP RECEIPT#
Workers Compensation unlnsumnwramal. ifiedcopy thcrcof(Scc.3gW,Lab C.)which PARK FEE Y—N—
covePolicy
all employee's under this Pehit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPP#
Pol cy#
Company BUILDING DIVISION FEES❑ CcniOed copy is berth'furnished. GAS-
CA.SYSTEM-OVER4(EA) PLANCHECK FEF.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthc permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.200F1'.
or less.) ENERGY FEE
I certify that in the performance of the wok for which Nis Permit is issued,I shall WATER HEATER WNENT/ELECfR
not ploy any person m a y mm er so as to become euhject to the Workers PAID
mansatimn lrws D e WATER SYSIEMTFIEATING
Q z Applicvmt Date Rcaeiptk
z NO'I'ICE'TO All ACANT:If,of n deg this Cerufiale of Exanption,you should NEW RESIDENTIAL PLM B SQ.EL
become subject m the Workers Compensation TOTAL:
E-' forthwith cam 'he
provmsmns of the Labor Code,you must
pr wi provision,of this Permit shall be deemed revoked., BUILDING FEE
per, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction leading agency for she perfommance of
U Othe work far which this permit is issued(See 3097,Civ,C) T L: ELECTRIC FEE
benders Name
O U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE —_
I cenify that I have read this application and sate that the above inform eam n
corec
E-' P-• t.l agree tocomply with all Cityand countyordinancesandsam lawsrelating to PERMITISSUANCF- MECHANICALFEE
p] building construction,and hereby ambnrixe representatives ofthis city to enter upon the 01
C) z abovomcnionod property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilitics,judgmcros,costs and expenses which may in any way cembea ossaCity AIR HANDLING UNIT(TO 10,000 CFM) r
7"""
"mmeeofthe mmin of tpt Permit.
r AIR HANDLING UNIT(OVER IO,000 CFM)
Sigmmmr 'Applicant/ onhe ate EXHAUST'HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,INXIBTU) Date Receipt#
applicantWill the applicant or Tareman building occupant store o,hnd,hreffle ha Health
a material
Code,
Section
the Cupertino Municipal Code,Chapter 9.12,and the Heahh and safety HEATING UNIT(OVER IW,OW BTU) TOTAL
Coda,Scdi0 25532(ap
❑Yu 0 N VENTILATION FAN(SING LE RFSID)
Will Joe applicantorfutumbuildingaccupantuseequipmemordeviceswhichemit BOILER-COMP(3HP OR 100,0((1 BTU) ISSUANCE DATE
Jnus air cnnuminam,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1 W,BBO BTU)) 4 B D
❑Yea ❑No NEW RESIDENTIAL MECII, SQ.ET.
H ♦ aJ
I have mad the haticandfelt'Code,
materiels requirements under 34.Chapter1 un erst of the L/ Fi 1-A4
CaliforniahebulHealth&Safety Code,Sections 25505,25533 and 25534. I undersand Nat r a7
if the building docs notmo ernallcurrently have r town.Nat n is my responsibility a notify the `VP
occupant of the rcquiremcros which moa ed met prior m issuance oro Cenirica¢of Cn,y
annpanoy.
Ilwncr nramhonmdagern Date A ISSUED BY:��I�
OFFIC