26724 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - BUILDING-hJ.ISLTNICAL PERM]'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 2 6 7 2 4
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPUCA'UONSUHMMMALDATE
LUNITts LOTH
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROLk
is RCHI,TEM/CT/FNGINEER: LIC AD RESS: ❑
J"
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
�--; �r� a93 -��i7 PERMIT ISSUANCE BLDG 11 PLUMP MF.CII
El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL.
p0..Z I hereby affirm that l am licensed under provisionsofChepter9(commencing with JOB DESCRIPTION
WOO Section 7").f Division 3 mf me Businessued Professions Code,and my license is in PANELS
zV1- full terve and if i
vaFiZw Date Cl s O-I' C'.1ZQ Cont 3 G UPT0200 AMPS
Q0. pare�! �"'�� Conmactor 201-1000 AMPS 1 �1
4'mZ ARCHITECTS DECLARATION OVER TO AMPS SQ.F0.FLOOR AREA $/SQ.41'.
W
OZ^
ZOwO— l understand my pleasshall be used as public records.
SIGNS ELECTRICAL
E x c,<
Licensed Professional
OW, OWNER-BUILDERDECLARATIONCommLON SPECIALCIRCUIT/MISC.
XOy V I ngma affirm that I am exempt ssa the Cosions Cs c:Any
Law for the
tJ3 tvFi following reann.($emion]03 L5,Business and Professions Code:Any city or county TEMP.METER O0.POLE INST.
F'
OJ which requires a permit to nm,tmeq alter,improve,demolish,or repair any structure
�0.'WQ� prior to its issuance.also requires the applicant for such permit to file a signed statement POWE0.DEVICES
Iy�pO that he is licensed pumuani to the provisions of the Contractors License Law(Chapter
0.0. E 9 commencln SWIMMING POOL ELECTRIC
( gwhh Swtinn]II(0)mf Division the Business and Professions Code) VALUATION
ce
m^hy or that he is exempt herefrom and the basis for the alleged exemption.Any violation of SWITCHES-
FZQSection 7031.5 by any applicant for a permit subjects the applicantm a civil penalty of OUTLETS FIXTURES
not more than five hundred dollars($580). (_0
W^4 EI I,asownerofmcpropeny.ormyemployttswimwagcsasmcirsolecompcnsadou,
NEW RESIDENTIAL ELECIR SQ,FT. STORIES TYPE CONSTRUCT ION
3iW5
v0 will dothe work,and the structure is not intended confined forsale(See J044,Business
and Professions Code:The Cnnuacmrs License Law does not apply or an owner of
property who builds or improves thereon,and who does such work hlmsel for through his
own employees,provided that suchimprovementsare not imcndedor offered forsale,If,
OCC.GROUP RGS.UNITS
however,the buildingor improvement is sold within one year ofcompletion.the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
E]
❑ I,as ownerofthepropcny,am exclusivdy<onuacting will licensed contmnmrsm QTY. PLUMBING PERMIT FEE 41006 ZONE ANN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lewdoes not apply marrow❑erofproperty whobuildsmimprova thereon.and PERMIT ISSUANCE
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&I'C far this reason MACK Il OTECT.DEVICE OUTSIDE FEES
PR
SANITARY Y N
Owner Data ORA S-FLOOR.ROOP.AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I herebyaffirm that l have a cenifirse ofeansem to self-iname,mamnificateof P ORES-PER TRAP RECEIPT ft
Wurker,:'Compensation Insurance or a certified copy mereof(Sce.3800,Lab C.)which PARK4EE Y N
coven allemp)oyee'}u9pc2 as AS-EA.SYSTEM-I INCA S BUILDING DIVISION FEES
Policy
9YRECEIPT#
d rY
Company �y x'•�-39'1 dy1 GAS-EA.SYSTEM*O rR PLANCHECK FEE
❑ Cenifiedcopy is herchy famished.
Certified ropy is filed with the city inspection division. GRHJkSF/INDUSTRL WAST v NTERC OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(This section need not be completed time permit is for one hundred dollars($100) SEWER-SANITAR TORM LA. 00 ENERGY FEE
or less.)
I evdify don in the performance of the work for which this pem,is Mined.l shall ATIiR H RW ENT/EL R
not employ any person in any maso a,to become subject to the Worker% PAID
Compensation Laws of Califomia. Date TER SY PA 0 Dam Receipt»
Q ,z Applicant
z 0 NOTICE TO APPLICANT:ILafter making this Certificate of Exemption.you should Nb RESIDENTIALP SQ.FT. TOTAL:
ty become subject tame Worker's Compensation provisionsofine Lalrm Code,youmust
foMwith ei mply wim such provisions onhis permit shall be deemed revoked. BUILDING M-
a [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm than them is a construction lending agency for the perfmmana of TOTAL: ELECTRIC FEE
U 0 the work for which this permit is issued(Sea.7099.Co.C.)
Lenders Name
0 F Lender,Addrea, QTY. MECHANICAL P17RMIT FEE PLUMBING FEE
U 1 certify that 1 have¢ed this application and.ata a that the above information is MECHANICAL FEE L 11
>" C correct. lagrceto comply wim all city arM county mdinancn and nate Inco,mlating to ( PERMIT ISSUANCE DO bo•eU
F' building concoction,and hereby aumona<represcnutivesofrhis city to enter upon the
above-mentioned rx r for inspection AUIERORADDTOMECH. CONSTRUCTION TAX
(� z au av Y pec n purposes.
(We)agree nt save,indemnify and keep hornless the Ciacco Cupertino a trinit
it,
liabilities,judgmem.v,coats and expenses which may in any way accrveu �' t id it, AIR IIANOLING UNI'1'(TO 10.00(CFM)
cnnscqucnceofthegrar ng fihis permit.
AIR HANDLING UNIT(OVER I0,0110 CFM)
Sil,miame of Applicant/Contment, DateEXHAUST HOOD(W/DUC) PAID
11 s Z s RDOUS MATERIALS DISCI RE HEELING UNIT(TO 100.000 BTU) e0 Date Rec<iptN
Will the applicant or future building occupantsmre or handle lecardous material k1EATING UNIT(OVER 100.000 BTU) TOTAL: 0 h
as defined by she Cuperino Municipal Cade,Chapter 9.12.and the Health and Safety
Code,Sect. 5320)? VIiMI'ILATTON FAN(SINGLE RFSID)
kcs ❑No
ISSUANCE DATE
Will theapplamair fmumbuildlngoccupartusee'u,cromindesica,whichemit BOILER-COMP OUT OR 100,000 BTU) pp
• M1aaardous air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(OVER IfO,fNp BTU) sP IA I D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hm:mdous material,requirements under Chapter 6.95 of the Nov 15 1994
Califomia Health&Sulety Code,Sections 255115,25533 and 25534. 1 understand that
if the buildlrgdocs rrnwrrand,have,nca nt.mat it i,my re,ponibdhy to ratify me 'C+I'1 Vr vwrCf1111NU
occupant of the requirement,which must be met prior an issuance of a Certificate of
Occupancy.
Owner or incl cd agent Dam TOTAL: 60.60 ISSUE.DBY: C
OFFICE