26602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.CTRI AL PERMITNO.
APPLICATION/PO`RMIT , PLUMBING-MECHANICAL ,2 C C(1
BUILDING DIVISION BUILDING PROJECT IDEN'rIF'ICATION L V UU
BUILDING ADDRESS: a � SANI'T'ARY NO. APPLICA'I10NSUBBMITTALDATTi
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CHIT/IH C1/I' GIN ER:, iI�„Il LIC ADDESSI Ave
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CONTA rMV•7•0 4 ^� PHO .7U
W1 P(��p/��//OO QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�'7 !O 6L BLDG ELECT PLUM MEC
PERMITISSUANCE �
LV
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
aci I herebyaffrm that l um licensed under provisions ofChapter 9(commencing with JOB DESC ION
m C O Smimn 7000)of Dirision 3 of the Business and Professions Code,and my license is in PANELS
<ZI—I-- fakrereeand-reset.
FZW License Clue Lic.# UPT02W AMPS
w Q or Dote Custraemr 201-1000 AMPS
I-y< ARCO II'I'ECTS DECLARATION SQ.IT FLOOR AREA $i PT.
ZO Vs— l understand my plans shell bo used a public mounds. OVER IIAW AMPS , 1
<—FI SIGNS ELECTRICAL
2 y j Licensed Professional1\ v
pit,
yv W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO W U 1 hereby affirm that I am exempt from the Contractor's License Law for the
u131a.h following person.(Section 7031.5,Business and Professions Code:Any city or County 1 P.MIS T'ER OR POLE INST.
rr I!C< which reyuires a permit In amslme6 alter,improve,demolish,or repair any swemre
zod Y� to its issuance atom res the applicant for such parent file a signed statement WF.R DEVICES
prior rrqui pp peau ger
'W<0 that he is licensed pursuant m the provision.mlthe Contractors License law(Chapter
aaa� 9(commencing with Section 7000)of Division 3of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W2 o, er that he is exerapuherefmor and the basis for the alleged exemption.Any violation of
l_Z{ Section 70315 by any applicant for a permit subjects the applicant o it civil penalty of ,E'rS-SWITCHES-FIXTURES
=a0 nm more shun fve hundred dollars(SSW).
n. NEW RESIDENTIALELECrR _SQ.FT. STORES I TYPECONSTRUCfION
L'F-p ❑ .1,ayswnemfthe property,ormyemployeeswi0t wagesuNcirsolccompensado
y302 will do Utcwork,aod Ute structure isnot imendedmixi for We(SecJ044,Businns f�
and Professions Cade The Commences License Law does not apply to an owner of
property who builds mimproves the enn,and whodoessuch work himselforthrough his
ddthmsuchim l t l ddornffemdforsale.TL OCC.GROUP RES.UNITS
ever.thecs,provi� pis sold nsaremo inane
however,thebuilding burden
fpm,iaiesoldwithinoseyear of impowe far maowner-
builder will have the burAcn of proving that he did not build or improve for purpose of
side.).
[1I,as evaerofthe property,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE 8.000 ZONE APN
comment the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law dues not apply loan ownerofpropeny who buildsor improves thereon and PERMITISSUANCE
who contracts for such projects with a c mo-aaoAs)licensed pursuant to the Comme
License Law. ALTER-DRAIN ffi VENT-WATER(EA) FEE SUMMARY
❑ 1 son exempt under Sec. ,B&P C for this¢awnBACK ROW PROTECT.DEVICE - OUTSIDE FEES
SANITARY Y N
Owner Date RF,CF.IPf B
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm that l have a cenifcate of consent to self-insure,or a«rtifiente of FIXTURES-PERTRAP RF,CF,IPr#
WorkersCompasmion Insurance oracertifled on,lhenced(Sec.JN00.Lob C)which 7;7PARK FEL' Y N
rs all amPloyee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECF #
Policy# ILDINGDI SIONFEFS
Company GSYS- EA.SYSTEM-OVEt4( ) PLANCHCCKF
❑ Certified copy is hereby famished. _
❑ Cmnif W copy is fled with the city iaspeedan dlvisioa GREAS IND StRL W%s5 t 1NTE lIVI R GRADING FF
CLRT'IFICAT'E OF EXEMPTION FROM WORKERS' GREAS 'TR'AP \/. 1� SOILS Rai
COMPENSATION INSURANCE
(This sectionnced rat lsaimar erred ifthe pernit is formic hundred dollars(S l W) SEWER-SANITARY-STORM EA. ENERG
or less.)
I certify rhes in the performance of the work for which this permit is iuued,Ishall TERH'
not employ any person in very n as to become suhjccl m the Wm3es' PAID
Compesmlies Lawsof Califmnin.Data sm WATERSYS'rENbTREA'I TNG Dur Re. ' I#
Z Applicant
ZNOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. INTAL:
F-' become subject o Ne Workees Compensation provisions of the Labor Code,you must
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. QSEISMIC FEE
CONS'1'RUCI'IONLENDING AGENCY
Iherehyaflum In.there is a consmuaion lecy ndingigenfur the perfommnce of ELECTRIC IFE
U O
the work for which this Permit is issued(Sec.301 Civ.C.)
" — Lenders Name PLUMBING FEE
F Lenders Address QTY. MECHANICAL PERMIT FEEASA
U 1 certify that I have read this application and stare that the above information is MECI IANICAL FEE
rd's (y respect. I agree to comply with all city and county onlinances and pore laws almingm PERMH ISSUANCE
ly" Ci
building amslcunion,and hereby amhodee reprcsenmtives of this city to enter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities'udgmrnu,cosu andeapenses which mny'a e,way attrveegainstsadd City AIR HANDLING UNLT(1O 10,000 CFM)
incon y race nfIW,pera Is Near AIR HANDLING UNIT(OVER 10,000 CFM)
7
,igama of Applicant/ mractor ate EXI IAUST I IOOD(W/DUC`U
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building occupant aom or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the hHEATING UNIT(OVER 100,000 BTU)
ealth and Safety TAL.
Cade.Swtien 255320)'! VENI'ILA'I'ION FAN(SINGLE RESID)
❑Yes ❑No 5 11
ISSUANCE DATE
Will thea licamer future building tune t ordevices which emit BOILER-COMP(3HPOR 100.000 BTU)
pp g by then qua Air
haeardous air conrsminanu as Defined by the Bay Area Air Quality Management BOILER�COMP(OVER 100,000 BTU)
Home? PAID
1:1 Yes ❑No NEW RESIDENTIAL MIiCl1. SQ.Ff.
I have read the hazardous materials reyuiremeals order Chapter 6.95 of the
California Health&Safety Cade,Sections 25505.25533 and 25534. 1 understand shat
Hthe building does not camently have a resaat,that it is my—possibility to notify the
occupant of the recuiremems which must bo mel prior m issuance of a Certificate of
Occupancy,
Owner m inghmrized agenl Date 'T T �� ISSUED ITY:
OFFICE