26797 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU U.Ilol:-RCECTRTOA' PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT 1-LUMRING-MECIIAN'ICAL nC7(�
RUILDINGPROJKCI'HRN'1'HWAI]ON Go I J
SANITARY NO. APPLICATION SUBMITTAL DAIS
UNITM LO1'#
OWN' sok74 rV �! PHONE.0 CO RAMORSNAM6: LIC NO: 3,Z NIC O �
L El«��;
•ARCHUr.0 OENGINIBIR: 4 LIC NO'. DI}P : G 1✓a k"
! O vfee,& 1c, le A vee 9
coergcT': - pxorve: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC11
PERMIT ISSUANCE . . 0 q- ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
I hereby affirm that l amlicensed underprovisions ofardifer9(commencing with
22100 Sectfullf ecandefDivision3of the Business and Professions Code,and my license is in ppNRIS � J
CuIE full fora wJ effect UPT0200AMPS
6 V UUR License Class Lim.#
so Date Contractor 201-IW"PS
ZOrn2: shARCHITECTS DECLARATION OVER I1000 AMPS SQ.Fr.FLOOR AREA $,SQ.FT.
0z-0 I understand my plats all be used as public records.
F��w SIGNS ELECTRICAL
Q� , Licensed Professional
Laa'6 OWNER BUILDER DECLARATION SPECIAL CIRCUOMISC.
0au I hereby nfron that Lan)exempt from the Conimclars License Law for the
u130N following reason.(Section 0031.5,liminess and Professions Code:Any city or county TEMP.METER OR POLE INST.
F' y which requires a permit to construct,alter,improve,demolish,or repair any structure
a� prior to its issuance,also requires the applicant forsuch permit to rite stagned statement POWER DEVICES
6 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a
aMz 9(commencin with Section 7" f Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
nmo, (commencing )o ) VALUATION
pr=y orthahe3L5bpnyapplicnt f the brmit subjects
spicmprinn.Any violnion of OUTLEI'8-SWITCHES-FIXTURES
7 Y Section Jot LS by any applicant for n permit xubjeots the applicant to a civil penalty mf
W ¢O not moremanrofhundred
epmMnollarmyempl NEWREADENTIALELFITR S
,Y ❑ I,amwneroHhepmpeny,nrmyempinyeeswith wegesas theirsolecompensauon, Qom' STORIES TYPE CONSTRUCT ION
y22 will Jo the work.and the structure is not iamadedoroffered for sale(See 7044,Business
and Professions Cale:The Connector's License Low does not apply to an owner of
property who builds or improves mention.and who dons such work himself or through his
own employees,provided that such improvements are not intended or offered for safe.If. OCC.GROUP RES.UNI'T'S
however,the building mirm rovemem is sold within one year of emapletim.the owner- L
hander will have he burden of proving that he did not build or improve for ampose of
sale.).
❑ I,as ownerofloympeny,sum exclusivefyeantraming with licensed contractors to QTY. - PLUMBING PERMIT FEE FLOOD ZONE APN
ansuuct the project(Sec.7o .Bminess and Professions Code:)The Contractors
License Luwdoes am apply to an ownerofpmpeny who buildsorimproves thereon,and PERMIT ISSUANCE
whormarectsfor such projects with acontmemr(s)licensed pursuant o the Contrecmrs ALTER FEE SUMMARY
License Law. (EA)
❑ 1 em exempt under Scc. ,p&P C for this reemn BACK FLOW PRO .DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RGCEIPI'#
WORKMAN COMPENSATION DECLARATION DRAWS-FL .ROOF,ARIA,GOND. SCHOOL TAX YN
. e❑ Thereby affirm thatl haveacmificam of consenuo aelr-udmra.oncemrramaf FIXTU .PF.R TRAP RECEIPT#
Workern Compensation lnsumnce or a certified copy thereof(See.3800,Lab C.)which PARK FEE Y N
overs all employee's under Nis permit. AS-EA.SYSTEMA INC.4 OUTLETS R17CE117 0
Policy# BUILDING DIVISION ITES
CompanyGAS-EA.SYSTEM- ER 4(IA) PIANCHECK FET?
[:I Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFJINDO TNSTI?INTERCVTOR GRADING EFF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPSOILS IEE
COMPENSATION INSURANCE
(fbis section need not be completed ifthe pemth is hours,hundred cut.(It ) SE -SA 1 RY-STOR o0P . ENERGY FBI!
or less.)
I canify that in the performanceofthe work for which this permit is issued,I shall WAIL H TR W/VE
not employ any person in any manner so m m become subject or the Workers' PAID
O z npprcam Compcnmbari Lawsof Califamia. Date WA'TEN'S E R Date Heceiptq
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should EW RESIDENTIAL I'Ll SQ.PI. TML:
p+ � becomesubject to the Workers Compensation provisions of the Labor Code,you mus[
a forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING THE
yW Q CONSTRUCTION LENDING AGENCY SEISMIC PEI?
z I hereby affirm that hem is a construction lending agency for the performance of
'U O the work for which this pined,is issued See.30397,Civ.C.) TOTAL: ELECTRIC FEE �a
LL. s--t Lender's Name PLUMBING PEI?
U Lenders Address QTY. MECIJANICAL PERMIT FEE
1 certify that I have read this application and state that the above information is
comet, lagru rocomply with ell city and county oNirwccs and state Iowa rtleting to PERMITISSUANCE MVCHANICAL FEE
F's y building construction,and hereby authorize rcpresentutives ofthis city to enter uponthe
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTIIUC'1'IONTAX
(We)agree to save•indemnify and kap harmless the City of Cupertino against
liabilities,judgmetns,cnns nxswhich mayin any wayaurueagainst said City AIR HANDLING UNIT(TO IBM)CFM)
n'uryenw t.
AIR HANDLING UNIT(OVER 10,000 CFM)
amre of Ap tnmt/Contracmr Date A EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(I'O 100,000 BTU) Date Receipt#
Will the applicant cr future building occupant store or handle hawed..,material BEATING UNIT(OVER IW,IgO BTU) 'fOTAI.:
as defined by the CuNnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scotian 25532(a)1
El Yes 13 No VENTILATION FAN(SINGLE RESID) rl
Will the applicantor fume built ingoecupant uxequipmemordevices whichimit
BOILER-COMP(31IP OR II--- BTU) ISSUANCE DATE
haeadnus air comominonw or defmed by the Bay Amo Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District! p '
❑Yes ❑No N13W RI3IDENTIAL MECtI. SQ.P �'1
f.
I have read the hazardous materials requirements under Chapter 6.95 of the ♦ LJ
California Health&Safety Code,Sections 25505,25533 and 25534. lundemundthat C//
�I /f ^-
ifthebuildingdoesnotcurrentlyhaveahand,that it is my responsibility to notify the y//Y �•9.`l�
occupant of the requirements which matt be met prior m issuance of a Cenificam of �//- —T
Owner or euthonzW agent Dara. TOTAL: ISSUED BY: JJ/y\ham