26424 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO tl MBIN.-61ECHA CALICA PIiNMI'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PING R OJECI I.CHANIFICA
BUILDING PROJECT'IUEN'1'IFTCA'1'ION 26424
BUIIAINGADDRESS}� /\/r SANITARY NO. APPLICAGONSUBMITTALDATE
(J • /Q , UNIT# LOT
OW !SNA F.:/s ♦ PHONE: CO R' E LIC NO: l
G HN N/C CON ROLA
�ARCHITE f iNGINHHR: LIC NO: ADDR
u3 tel a Rd YX El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT IEE BUILDING PERMIT INFO
Al ELECT PLUMB MEII
❑C
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )Oil DESCRIPTION
J900 Ihereby al Division 3 ofth Busio,smad Psed rofessions
Cpter wJc, commencing with
atilOp fallSection 71x10)of Division3of the Business and Professions Code,anA my license is in PANELS, /r
6�❑, full!ceatN cffcn. /i
zz License CI .. Lic.# v-[ UP T02W AMPS
y 6 y
Data Convector 45- 201-1000 AMPS
2FO rNis Z.a CHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ,Ff.
CZ-0 I understand my plans shall be used as public records. IT�k
<=f d Licensed Professional SIGNS ELECTItICAl //� E L 9
W�srrZ�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. f� 1\ I—
X��pU.. I hereby affirm that 1 am exempt from she Contractor's License law for the 1 1\�1
sn31>-m following mason,(Section 7031.5,Business and Pmfessiom Code:Any city or county TEMP.METER OR POLE INST. - h\/'J�UUU
which requires.permit to consa er,.her,improve,demolish,or repmr any strsecsart
Embark,iuissuance,.1sonidnes Neapplicanl for..ch prnit".Gle.milmod sademcm POWER DEVICES TE
so C p that he i.sJfire nsed Pa.... to the provisions of the Contractors License Law(Chapter
4p P4 9(commencing with Section 7")ofDivision 3 office Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ty_,,, orthat he is exempt hcmfrom and the basis for the alleged exemption.Any violation of
F• a Senion 70115It eny appfcim fora peormtsahjects the applicant to o civil Penalty of OUTLET'S-SWITCHES-FIXTURES
t more than Rve hundred dollars($500).
p n❑ 1,usnwnensftheprnpeny,nrmyemployees withwagesnstheirsolecompens.tion. NEW RESIDENTIALELECTR _SQ.PT. STORIES TYPE CONSTRUCTION
a3- tilldolheworkand theamemre isnot intended proffered forsale(SecJ04q Business
and Professions Calc:The Contractor's License Law dnev not apply 10 an owner of
property who buildsorarpmvesihereon,andwhodoessuch work himselfor through his OCC.GROUT' RES.UNITS
own craployees,prnvided moment improvermarx re not intended or offeredfnrsalc.Jr.
however,the building or improvement is sold within one year nfrnmpletion,the owmer-
builder will have the burden of n that he did not build or improve forpurposeof TOTAh:
proving pr
❑ Lus nwnendthe Propeny,emexclusivelycontracting withliansed ronvacmmk, QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's
License Lawcovanotapply loan owncrofpropertywho builds or improves thereon,and PERMIT ISSUANCE
whorontmcts fursuchpmjecss with C contract. .)licensed......tmthe Contmctor'v ALTER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ I can exempt under Sea. ,B&P C far this rt.son __ OUTSIDE FE
BACK FLOW PROTECT.DEVICE SANITARY Y_N
all Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMificam TIONDECLARATION SCHOOL TAX Y N
tri Cio affirm that 1 have a certificate of consent r of(See 39,or a ani.)i which
of RBCF:IPf p
Fl%TURES-PER TRAP
Woea.1 Cnmpensetion lnsumncc ore certified copy fhereo((Sec.38tK1,Lab CJ which PARK FEE Y N
oco,is all rntp�`e JtdcoNig�snjy /2(r GAS-EA.SYSTEM-I INC.4 OUTLET'S BUILDINGDIRECVISIONFEES
Policyp CCIICHI LL lI 9 -!
Company �1#avai GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cid ropy is filedherewfhhe,id.
enifiel copy is filed with the cito,inspersion division GREASE/INDUSTRL WASTE INTERCEPTOR GRADING PEE
CI?RTIFICA'1'11 OFEXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thin section need nm be completed lfthe Permit is for one hundred dollars 1$100) SEWER-SANITARY-STORM EA,21101"I'. ENERGY FEE
or lens.)
I cerdfythat in the perform.nmofthe work for which this permit is issued,(shall WATER HEATER W/VENT/ELECI'R
not employ any person in any marmer so as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEWGEATING Date Receipt Jr
p z Applicant
z O NOTICE TO APPLICANT:If.after making this Certificate o(Examption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
t•+ LO) become subject to she Workers Compensation provisions of the Labor Code,you muss
7 forthwith comply with such provisions orbis permit shall be deemed rtvokcd. BUILDING FEE
pw, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I Is mby.ffirm that there is a commuci on lending agency for the perfortnsntt of
V O has work for which this permit is issued IS..3097.Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name PLUMBING IEE
O (~ Lender's Add.. QTY. MECHANICALPI?RMIT FEE
V 1 certify that I have read this application and state that the above information is
atorten.l agree In comply with all city and county ordinances and state laws miming to PERMIT ISSUANCE MECHANICAL FEE
H-t y building construction,and hereby authorize representatives orl city to enter upon the CONSTRUCTIONTAX
U ahnvani,minned popery for inspection purposes. ALTF.RORADDTOMECIL
(We)aura to save,indemnity and keep harmless the City of Cupertino against
Iiabilitics,judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
c...esryence of the grunting of this permit.
ATR HANDLING UNIT(OVER I0,M)CFM)
Signature of Appiicam/Contmnor Date EXHAUST FOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,WO BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW,B00 BTU) TA :
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Ileahh and Safety
Code,Simon M532(a)? / VENTILATION FAN(SINOLI?RfiSED)
❑Yes [yam
BOILER-COMP(3HP OR IOBWO BTU) V
ISSUANCAT
Will the.pplicamorfwumbuildingoaupanmsecquipmenmrdevicnwhich emit sTq 0 t
• haz°rdous air contaminants as defined by she Bay Are.Air Quality Management BOILER-COMP(OVER U117,000 BTU) (T
Dinrics7 t-#{/
❑Yca "' NEW RESIDENTIAL MECH. SQ.IT.
I hove read tic y Code,
materials requlremants under Chapter understand
of the �,5� %P•jls
(klifnmiu IlnJth& albty Cnde,Sections 25505,25533 and 25534, l undcrxmnd that 1B1w „U
ifthe buildini Jo otrnrmittly ave a tenant,that it is my responsibility tit notify the
cupam nl tic doememx sic s t prior issuance of Ceit i I of
Ottvpn"'
Owner or, tharizcJ truck, ate TOTAL: ISSUED BY:
OFFICE