26735 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bun:DINT:-ELECTR I,A, FERMI T No.
APPLICATION/PERMIT PLUMBING.MECHAn'CAI, C 7 a0 C
BUILDING DIVISION BUILDING PRO.IEMADENTIFICA'FlON v / J J
BUILDING ADDRESS: ' SANITARY APPLICAIIOIONSUSUBBMAl.DATE
2 O 9 ceV ✓-e-eI✓lWIT'H A/00
LOT#
OW SNAM I. t PHONE: CONTRACTOR'S NAME: 57*,
LIC NO:
4 a Z T S7'f I 2 6a N/C COMROL p
ARCIII'fF.C'I :NGINI?IiR: LIC NO: A RESS: ❑
:ON'I'ACI': - PRONE:
IN
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT FO
L L aM I 0 h ys3 -�ri o CE BLDG ELECT' PLUMB ME❑CH
'4KGl\ Sif t PERMIT ISSUAN
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB FSCRIPf1ON
OIYZ Iherebyaffrmdint l um licensed ander provisions of Chapter 9(commencing with _
FOO Section 7112)of Division3ofthe Bminessand PrefoximnsCme,and.,It..is in PANES' �1
utU��11--. full fine,anJefl act.
Q^ yVj U se C1-s .. Lie.# UP TO 200 AMPS
N �• 's Conuucro, 201-1"AMPS
ZOy-- ARCH]FECI'S DE LARATION OVER H3p0 AMPS ��
KOaU �I�FIAREA FT.
O'Z'-' 1 nndersnmJ my plans shat l be used as public rttmds.
SIGNS ELECTRICAL
Poti�eql
Licensed Pnmfcssianal OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractor's License Law for the
,
Wi O y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
��� which rc use it ow,m con nott,alter,improve,demolish,or repair any atmdum
Y� priormits issuance.ulsurcquircx the applicant forsuch permiuo fileosigned sta¢menl POWER DEVICES
� �0C that he is l icensed pursuant to the provisions of the Conracmes License Law(Chapter _
d.,C 9(commencing with Section 701 of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION�y.
W❑,� or that he is exempt therefrom and the basis for the alleged exemption.Any violmionof
FZa Section 7031.5 by any applicant fora permit mb'om,he Recent to ecivil I.LTS-SWITCHES-FIXTURES K\ \—]`.lr•�;
J pp penalty of
not more than five hundred dollars(Sem).
tY�p ❑ LasowneroDM1epropeny,ormyemployceswithwagcsestheiraolecrmtpcnsatioa NEW RESIDENTIAL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
will du the work.and the structure is not intended oroffemd foraale(Sm.7(1 Business
and Professions Cade:The Commenon s License Law does not apply to an owner of
prnpeny who builds orimproves thereon,and whodrawsuch workhimselforthmoghhis
ownemployesm.provideal that such improvements=not intended muffered forame.If, OCC.GROUP RES,UNI'T'S
however,the building or improvement is sold within one year of completion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
5d1e')' y. QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Las theonvproject
r jeth(Seen ,14.Business
s with enntracrmrsm
answer the project(Sec.]814.Business anti Professions Code:)The Contractor's
License Lawdoes such
whosedpamimprovee Courrn,and I'F.RMI'1'ISSUANCE
whence Laws for such projects with acnnroaogs)licensed pursuanuo the Conwetors
License Law. ALTE0.-DRAIN ffi VENT-WA'T'ER(EA)' FEESUMMARY
❑ [.exempt under Sec. ,B&PC for this mason BACK SLOW PR .DEVICE OUTSIDEFEES
SANITARY Y N
Owner Date DRAINS-FLO ,ROOF.A ,COND. RECEIIv #
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y—N—
EI
I hereby affirm that l have acenilicamofcarom to self-insure.ora certificate of RECEIPI'p
Workem'Cum FIXTURE ERTRAP
pensmtion Insurance ore ocrtifed copy therwf(SCo.3flm,Lab CJ which PARK PEE Y N
covers all cm to se's undo,this t RECEI '#
Policyq p y permm GA -EA.SYSTEM-1 INCA OVfLETS BUILDING DIVI ION FEE
Company AS-EA.SYS .M-OVE 4IRA) PLANCHECKFELs O
C1 Certified copy is hereby fulashed.
❑ Certified copy is Bled with the city inspection division. GREAS .WAS CEPA GRADING FliF.
CERTIFICATE OF EXEMPTION FROM WORKERS'. GREASE SOILS FEE
COMPENSATION INSURANCE
(This section need not borampleted ifthe permit is Forms,hundred doHim;(SI EWNITARY-SJtRM E. FT. ENERGY FEE
ror less.)
I certify that in the pe,(o,munce of Ne work for which Nis permit is issued,lshall HEATER /ELE
not employ any person in any manner ao as to become subject to the Workers' PAID
Campenmtion Lawsof Califomie. Date WA' ST R- TING ate Receipt#
O Z Applicant
Z NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should N RESIDENT' LPLMI7. SQ.PT. 'TOTAL:
.V. becorecar ect mthe Worker's Compensation provisions oftho L.NaCode,you must
a , forthwith comply with such provisions or this pewitsball be dcent revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SI?ISMIC PEE
Z I hereby affirm that there is a coresoamlon lending agency for the performance of
U O�+ the work for which which this permit is issued(Sec.3197.Civ.C.) TO'T'AL: ELECTRIC FEE
LI. t-^ Lcndeh Name PLUMBING FEE
U Lenders Address QTY. MECHANICAL PERMIT' FEE
I certify that 1 unmoral this application and smm thin the above information is
context. Iaymet.omplywithallckyandrounty oNinanccs and sm,lows relmingm PERMIT ISSUANCE MECHANICAL FRF.
DO building construction,and hereby authorize representatives oflhis city to enter upon the
U olxrve-mentioned properly for inspection putpusw. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(Wo)agree to save,indemnify and keep harmless the City of Cupanirm against �.
liabilities,judgments,consand expenses whichmay,in any way sccmeagamst said City AIR HANDLING UNIT(TO 10,01))CFM)
in ran.wit ecofthc mru of this pwmit.
AIR HANDLING UNIT(OVER IgOm CFM) -
nawmra Applicen Tactor Date EXHAUST'HUD PAID
IIAPARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 H'1'U) Date Rece #
Will the applicant or future building occupant stns,or handle hazardous material IEA'I'ING UNIT(OVER IIg1,oIX1 BTU) T
ow&food by the Cupertino Municipal Code,Chapter 9.12,and tho Health and Safety
Cade,Smlmn 25532(a)1 I
❑Yes ❑No VRMfIIATION PAN(SINGLE:RESID)
BOILER-COMP(31 IF OR I(injo IB B1 U)
ISSUANCE DATE
Will the epplica inums uas baldefined
by the
nBay Aresqua it Quality Ma ageme t P !k ' D
hazardous air com:uninums as def ted by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) Pi
District?
❑Yes ❑No NEW RESIDENTIAL.MECIT SQ.FT. JUL Q Q ���
I have read the hazardous materials requirements under Chapter 6.95 of the 26 Q
Califomie Health&Safety Code.Sections 25505,25533 and 25534. 1 undetamnd ilial 'r� /1 �/
if the mildingdoes non rocaly have a tenant,that it is my responsibility m notify the 1 Lill' LUt-1:K I1Ny `/�1
cecupam m rhe mqulrcmrnts which must be mw prim m issuance of n Cenificam of r t ,`//
Occupancy. ��[�����, ///((({{{///%%%)))JJJ
Gwner or omhorized agent Date TOTAL: ISSUED BY,