26477 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IEI:DTSG-F.T:ECTRTCA PERMITNO.
APPLICATION/PERMIT PLUMBING MECHANICAL, 26477 77
BUILDING DIVISION IfU1LDING PROJF:C'TIDEN1'IF'ICA'DUN
f�
BUILDING MDRE2SS: /I pa ^'��I //�(—]I/ SANITARY NO. AIILICA110N SUBMDI'ALDNIEI, UNITN LOl'N �r
OW RSNA PHONE: CONTRACTOR'S NAME: LIC NO:
s NIC CONTROL p
RCHITECT LINT ER: LIC NO: ADDRESS: ❑
CONTACT': PHONE Q.Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I -� EJ
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OZZ I herebyatfmt that l am licensed andapmvislonsofC apter9(wm 6ngwith 1 DCSCRIPI'ION
000 Scction](NNp of Division3of the Business anJ Professions Cad,wd mylicenseisin PANELS
C�F Bill lorce unJ cffcc
F0 U � UP TO 200 AMPS
Z,.y Licens Class sN LiuN C 1
oe� Dutc Conwcmr p v�/ 201-IOW AMPS SQ.FT.ET fid $/SQ.FT.
FyZ ARCHITECTS DLCLARATION_
Z 0 OVER HINT AMPS
OZF� 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Y J
Licensed Pr.fcssional
y,U
OWNER-BUILDERDECLARATIONThe CoATION SPECIAL CIRCUIT/MISC.
Wig W 1 hereby n.Se that 1 am exempt from the Consumers License Law for the
FW LL O a following reason permit
]OJLS, t,slows and improve,
de oro Cade:Any city county ante TEMP.METER OR POLE INST.
.] which i,s i..a permit to construct,alter,improve,h Permit t m repair any momum
Ft,Y0 that hoslicensed ,rsa requires thevisios of The Contractors
rile aligned aJ ffilemean POWER DEVICES
C
,,<0 that M1c is licensed pursuant the provisions of the Contrectoh License Lew(Chapter VALUATION
�—.0PareSWIMMING POOL ELECTRIC
a p'e o 9 that hencingexempt therefrom
andon he Division Sof.heed exemption,
vote Cade)
Wim Section
h7031.5 by thcrcfr.m and the ba.itsfor bles.thedexemant to civilprnally of
z Q Seni.n]II}L5 by any npPlicovl far a permit subjects the applicant to a civil perully of OUTLETS-SWITCHES-FIXTURES
not mom than five hundred dollars(1500).
�_❑ NEW RESIDENTIAL ELECTR SQ,ET, STORIES TYPE CONSTRUCTION
yF� ❑ Lasownerond the
muris or intended
Includeir sole cumpensiness
6'3 will Prod.fessions
andthe he Contranor is License
eseLaw does not
to an Business
and Profusions Code:the Contractors License Law Jas not apply to an owner of
property who bui Ids or i reproves thereon,and who dins such work hi troa If or Through his o
employees,provided dotsuch improvements not nm intendederoReredforsale.If, OCC.GROUP EAI
UNITS
however.the buildingor improvement is sold within one year ofeumpletion,meowner. O
builder will have the burdenf limitation that he did not build or improve for purpose of
°1I`')" QTY. PLUMBING PERMIT FEE FLOOD ZONEN
❑ [,;is m s owner ofthe property.nexclusively contracting with licensed contractors to
construct the project(Sea.7014,Business and Professions Code:)no Contractor's
Licens,l.awdnes nmapply man.wnerofpr.perry wm omldsor improvestherson,and PERMIT ISSUANCE
who contracts for such projects with a contractor(s)licensed pursuanuothe Conaactor''s ALTER-DRAIN&VENT-WATER L
License Law. ('A) FEE SUMMARY
❑ 1 am exempt unJcr Scc. .D A P C for this reason BACK pLOW PROTECT.DEVICE O TSIUE PEES
SANITARY YN
Owner RECEIPTp
WORKMAN COMPENSATION OECfARARA DRAINS-FLOOR.ROOF,AREA,COND.TION SCHOOL TAX YN
❑ eWCo affirmoThat nhranceve a oracca.eofcopy maose(Scx.3q.r sat,C.) hicklsof FlXTURES-PER TRAP R1?CGIPIp
covers I employ inion Insurance or ecenifed copy Hereof(Sec.38W,lsb CJ which PARK FIiF, Y N
Policy Nll cmploypc'Ni uhio-ge tUtn — GAS-CA.SYSTEM-IINCAOUTLEI'S RECEIPON
YY abb�N 1 BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHEC
❑ Cerifed copy is hereby famishes.
N Cenilied copy los fled with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADIN FEE
T
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIL TE
COMPENSATION INSURANCE
(TTisxxti.n need not M:<nmplemdifthe permit is for one hundreJ dnllam(1100) SEWER-SANITARY-STORM EA.200FT. E R
or less.)
I certify that in the perfomunce of the wool,for which This permit is issued.I shall WATER HEATER W/VENDELECTR
nm employ any person in any manner so as to become s bj t to the Worker.' PAT
Compensation ws fCalifnmia. Dam ' OI WATER SYSTEM/IEEATING ReceiptN
zQ NOTICE TO APPLICANT:IL afterm ng Nis Ccnifcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. / TOTAL:
Inhccomcsubject to he Worker's Compensation pfovisiens.flhc Labor Code.you most
� , forthwith comply with such provisions or this permit shall he deemed invoked. BUI FEL
[] CONSTRUCTION LENDING AGENCY ISMICEEE
I herchy action that is a construction lending agency for the performance of
L1 O .be work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: GLECTRIC E
Lender's Name
u-' F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMB GFEE
0 U 1 lenity that I have read this application and stem that the shove information is M NICAI.FEF.
D-1 correct.l agree m comply with all city and county ordinances=it an laws relatingm PERMIT ISSUANCE
buildingcunswcdwo.and hereby amhanse represeamdvu alibis city toenter upon the CONSTRUCTION TAX
U Z move-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless It,City of Ctiamino against
liabilitiesjjuuddgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
inconx9(� ,zu rg��f s roti/t�Dy &�3%9f
/r AIR HANDLING UNIT(OVER 10.000 CFM)
Signa ce of Applic nwcmr IF f Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MAI TRIALS DISCLOSURE HEATING UNIT(TO I0d,000 BTU) Date Receipt IT
Will the applicant or future building acupent store or handle havandous material HEATING UNIT(OVER 1011"BTU) 1-:
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25932(x)? VENT'RATION FAN(SINGLE RESID)
❑Yes
ISSUANCE DATE
Will the applicant or future building compact use equipment ordevices which emit BOILER-COME(THE OR 100.010b BTU)
hniarJous air nmmminantn as defned by the Bay Are.Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Diwnct?
❑Yes El No NEW RESIDENTIAL MECIL SQ.FT. pp1' as 1994
1 have read the hazardous materials requircn¢nts under Chapter 6.95 of the J�1v 3 y
California Health A Safety Code.Sections 25505,25533 and 25534. 1 understand Nat
if dm building does not currently have.tenant.tJam it is my responsibility..notify the V Ur Gr
occupant or the requirements winch mast he met prior to issuance of a CeniRcate of Cjl1 Y ur
Occupancy.
Owner or malumaed agent Dole TOTAL: ISSUED BY:
OFFICE