26366 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELM I RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. �` C
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION V 6
BUILDINGAIIDRESS: SANITARY NO. AW'LICATIONSUBMITI'ALDATE
x OO q-) ON Q T T UNIT. LOTIt
IG-
OWNErRACTORS NAMELIC NO:IOO/ NIC CONROLpAOrt PIS")(O0_
ARCHITEC`DENGINEERo LIC NO:
ADD
CONTACT
^ v/ ] ❑
CONTACT: PHONE: of BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
NLUC ELECT PLUMB MECI1
PERMIT ISSUANCE ❑ ❑ S El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Y
M=Z Ihereby affitm that l am licensed underprovi.smasof Chapter9(commencing with JOB DESCRIPTION
f-']O_O Section 7000)of Division 3 oldie Business and Professions Code.and my license is in PANELS
F full force and elle / .—w w-
Fz� Lic .esLIuex 3 LIC.. 1 �I UP T02W AMPS &IR L" s
y« me.,}Comm fir"' Y.zJ P�tA 201-HM AMPS v_"OO �W""'
F y ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.I100R AREA S/SQ.FT.
OO H D 1 understand on,plan shall be used as public records.
W SIGNS ELECTRICAL
Q,y j Licensed Professional
WyceQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OW, 1 Comby affirm that 1 am emmpt from the Corrientes License law for the
ul3my tbllowing reason.Section 7031.5,Business and Professions Code:Any city oreounly TEMP.METER OR POLE INST. /�
O; which requires a permit as construct,alter,improve,demolish,or repair any strucmm (v^,
Iii p�T� prior to its inuunee,also requires the applicant for such permit file a signed statement POWER DEVICES
K Q p that he is licensed pursuant to the Provisions of the Contraors License Law(Chapter
o-L0W ct
9(commencing with Section of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC V UATI
IsX]�",o, or'hat he is exempt herefrom and the basis for the alleged exemption.Any violation of
I-•ZQ Section]031.5 by any applicant for a permit subjects the applicant in civil perem,of OUTLETS-SWITCHES-FIXTURES V�
¢ not more than Five hundred dollars WOOL xiii
NEW RESIDENTIAL ELECIA SQ.FT.
c,10� ❑ 1,asowncrofthepropM,ormyemployeeswithwagcsastheirsolccompensatinn. TORIES TYPECONSTRUCrION
,3L will do the work,and lhemocoame is nut inteadedmnffered forame(St .70M.Business
and Professions Cede:The Contractors License Law doss not apply m an owner of
property who builds or impmens there m,and who does such work himself or through his
own employees,provided that such improvements amnotimmmded.roffered forsale.If,
OCCG UP RIS.UNITS
ma,eve.the building or improvement is sold within one yearofcompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for puryore of
sale)' QTY. PLUMBING PERMIT FEE LOU ZONE "N❑ am
I,ast r.fthe pPenm
y.nexcluavely contracting with licensed contreamn to
construct the project(Sec.70de6,Business and Professions Cade:)The Contractor's
Liccnselawdoes nm apply to anownerofpropenywho builds.,improvcstbeaa.,and PERMIT ISSUANCE
whntmn
ococtsfor such Projects with ac. tra.g
os)licensed puuant rsI.Me Contractors ALTER-DRAIN&VLNT-WATER EA
I—mov Law. - HFA) FEE SUMMARY
❑ I am exempt undo,See. ,B&P C for Ilia reason BACK PLOW PROTIiCT.DEVICE OUI SIDE FF,BS
SANITARY Y N
Owner Dae RECEIPT.
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Iberchyaflirmlhalhaveacenificaieofconsemmscl6iasure,or�CCnificam0l pIXTURES-PER B'RAP RECEIPT,
�W.rken'Compeneation Insurance or a certified copy thereof(See.380,lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT.
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 Bln) PLANCHECK hili
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEL(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASI39'RAP SOILS FEE
COMPENSATION INSURANCE
/This section need not be,completed ifthe permit is forone hundred dollars(S 100 SEWER-SANITARY-STORM EA.20FT. ENERGY FEE
s)
I artilymut inthepirforcrion.aor
any
re,
ecomehiubjec—it o issued,Workers' WATER IIIATER W/VENT/GLECTR
not employ any person in any manner so az 1.become subject m IM1e Workers' PAID
Compensation Laws of Califomis. Date WATER SYSTEM/I'RFATING Date Rcccipla '
C) z Applicant
Z C NOTICE TO APPLICANT:If,tone,making this Cenificamof Exemption,you should NEW RESIDENTIAL PLMB. SQ FT. TOTAL:
(n becomembjeCt m the Worker's Compensation provisions of be Labor Cod,.,m most -
a 7 hurNwilM1 comply thxuch his hall be deemed revoked. BUILDING FEE
PYwi provisions on permits
0. Q CONSTRUCTION LENDING AGENCYSEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of T ELECTRIC PEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name PLUMBING FEE F Leader's Address QTY. MECHANICAL PERMIT FEE
U 1 certify that 1 have read this application and state that Ne above information is - MECHANICAL PEE
correct.lagreeloe.mply with all city aMcnuntyonlirmncesendame laws relating 1. PERMIT ISSUANCE
building construction,and hereby vuthorize repteacradves ofthis city to enter upon the CONSTRUCTION TAX
U Z above-menilnned pmpstly for inspection pur ose.s. ALTER OR ADD TO MECH.
(We).grea m save,indemnl(y and keep harmless the City of Ca,mm against
liubilitien.judgmenu,costs and expenses which may in any way accor gams t id City AIR HANDLING UNIT(TO I0.000 CFM)
ce of the granting of this permit. 11
{` AIR HANDLING UNIT(OVER 10,000 CFM)
Signature.( 'licanVCormasem, { els EXHAUST HOOD(W/DUM)
PAID
IIAZARDOt15 MATERIA.. DISCLOSURE HEATING UNIT(TO 10,000 BTU) Dam ReceiFta
Willum.,licant.r future building occupanlsmre or handle haacoman material HEATING UNIT(OVER 100,000 BTU) TO"1'AI'
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heailh and Safety
Cade,Section 25532(.11 VENTILATION PAN(SINGLE RESID)
❑Yea ❑No
tlOILER-COMP QHP OR IMNgl BTU) Ry ISSh{A EDAT
F;
Will theapDlicant at future buildingoccupam use equipmemordevicu whi<hem ,
il If- �( 6
�
mrdous air comermemocs as defined by the Bay Area Air Quality Managerte0
tot BOILER-COMP(OVER IW,0BTU)❑ II11�� 1 11 oAA
Yes ❑No NEW RESIDENTIALMECH. SQ.FT. IpIIAY 199T'
I have mad the hazardous materials requirements under Chapter 6.95 of the /s f.
Culifomi.health&Safety Cade.Section,25505,25533.nd 25534. I understand that CITY OF CU EH I WO
Ilthebuildingdossnotencims lyhuvcast be thatitis myresponsihility enotify the
kcupant of the reyuiremen¢which run he mel prior to issuance of a CeNficam of
Occupancy.
Owaeror authori'eed agent Date TOTAL: ISSUED BY:
OFFICE