26317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINONot-kbul,rRICM PERMITNO.
BUILDING,DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL 26317 61
3 7
BUILDING PROJECTTIDENDF'ICATION (�
DRESS1SANITARY 0. 1 APPLICATIO
N SUBMITTAL DATEBU'DJ4
LOT N �
OWNERS# E: PIG, F CO A OR' NAM` LIC NO: lY ��w//- ���•••
tFE ll0 14��.1(� S� } �o N/C CONTROLa
ARC10'IECT/BNGINEER: LIC NO: ADDRESS: ❑
COM'ACI': I'110N1?:
QW. ELECTRIC PERMIT FEE BUILDING PERMITINTO
BLDG E PLUMB MI?CH
PERMIT ISSUANCE
LICENSEDCONTRACTOR'SDECLARATTON APPLIANCES-RESIDENTIAL JOB DESCRIPTION
cmz I herebyaffirm that l am limmedunderprovisions of Ch ater9(commencing with
t 00 Section 7")of Division 3 of the Business and Professions Code,and my liune is in PANELS
tC 151mme and WC
it
Imea_
C 20 �ta _ e1-I" S
T.O 2 ARCHITECTS A 1 OVER TBW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
qq 1 understand my plans shall W used as public records.
9qv sy SIGNS ELECTRICAL g� 11 fN is ;rs L E 9 � N
G]G] Licemcdl'milessinnul 6 11LI�J /_\ II
OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
301V, wing reason. m that I am exempt from thr Contractor'ssCo License Law for the �"p i\ /I j� i=
whit
following a a(Section 7031.5,Business and Professions Crede:Any city or county TEMP.METER OR POLE INST. 1'IiLr- ( IIt A rn
r which rcyuiren u permit to construct,alter,improve,demolish,or repair any swcture
a Q prior to its issuance,also requires the applicant forsachPont torileasignedstatement POWER DEVICES O
uCCCCm� Q 0C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
LL4 9(commencing with Sapar7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
P. or that he is exempt dherefmm and the basis for the alleged exemption.Any violation of OUTLL'TS-SWITCHBS-FIXTURES J
�z¢ Section 7031.5 by any applicant for a permit subjects the applicant no a civil pantry of
Kss not more than f ve hundred dollars($SW).
Fo ❑ I,mUwnermfthepropeny.ormyemployeawith wogesmdheirwlecomprnsedon, NEW RPSIDENTIALELECfR _SQ.Fr. STORIES TYPB CONSTRUCTION
will dolbework,and the structure imm imouledoroffereA forsale(Sm.7044,1usbacs
and Profasimns Code:The Convector's License Law does no,apply to an owner of
property who builds orlmproves thereon,and whodcax such work himselforthmugh his OCC.GROUP RES.UNITS
employees,Provided that such improvements are not intended or offered for sale.IL
however,the building orimprovemem is sold within one year of completion,tee owner.
hailder will hive tee burden of proving that ee did not build or improve for purpmo of
s Ic.).
❑ I,usnwnerofthepmpeny,amexclusivelycmmnmctingwithlicensedcomraamrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE? MIN
construct the project(Sec.7Ba4,Business and Professions CmR:)The Conuacmre
License Lawdoes notapplyto an ownerofprmpeny whohuildsor improvestherean,and PERMIT ISSUANCE
who contracts for such projects with a commex r(q licensed pursuanuo rhe Comesctote
Licanu Law. AI:TER-DRAIN&VENT-WATER IRA) FEC SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE E
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iheubyaffirmthat l have amniGcateofconsere toulLinsure,ore«niftcamof FIXTURES-PER TRAP RF.CEIPTN
Worker%Compensmion Immature oracertl0ed copy therenf(Ser.3800,Lab C.)which PARK PER Y N
coven all employee's under this permit OAS- RECBIPT p
Policy p EA.SYSTEM-1 INCA OUD.HTS BUILDING DIVISION FEES
Company GAS-HA.SYSTEM-OVER 4 BEA) PLANCHECK FET?
❑ Caddied copy is hereby famished.
Ccroned copy is filed with the city inspection division. GREASE/INDUSTR,WASTE INTHRCEPi'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Mria section neadma be completed Elba permit is forma,hundred dollars;P$100) SEWER-SANITARY-STORM EA.20011f. ENERGY FEE
or Ica.)
I certify that in the perfarmaneeof the work for which this permit is ismad,I shall WATER HEATER W/VENT/ELECfR
not employ any person in any moaner so as to hecome subject to the Workers' PAID
z Compcnationlawsof CalifUmia. Dare WATER SYSTEM/TREATING Date Receipt#
yy�
Applicant TOTAL:O NOTICE TO APPLICANT:IL slur mekingthis CmlHeme of Exemption,you should NEW RBSIDC•NTIAL PLMB. SQ.FT.
F7 V] become subject to the Worker's Compensaman provision.of the Labor Code,you must
forthwith comply with such Provisions or this Permit shall W deemed revoked. BUILDING,FEE
W CONSTRUCTION LENDING AGENCY SEISMIC ME
5 z
1 hereby uffrm that Here is a construction lending agency for the performance of
V Q the work for which this permit is issued(Sm.3097,Civ,C.) TOTAL: ELECTRIC FEE
O �r•+ Lender's Name
t••' Lcndim,Address QTY. MECDANICALPFiRMIT FEE PLUMBING FEE
V 1 certify that 1 have read this application and aide that the above information is
�" Da correct I agree m comply with all city and county ordinances and stare laws relating te PERMITISSUANCE MECHANICAL PGE
(•-' y building convection.and herebyauthmire representatives oftbiscidy memaupon the CONSTRUCTION TAX
V Z eboveme ' ted propeny far impaIion purposes. ALTER OR ADD TO MECI I.
e7 m save ' damnify end kap harmless the City of Cupertino against
ilitia dgmenk,f u ndn coos which may in anywryecerue againm svd Ciry AIR DANDLING UNIT CIO 1(1,1100 CFM)
na tee eof th Nis Permit .
AIR HANDLING UNIT(OVER 10,Ig)0 CFM7
5' .ave nl'ApPlic Co.
Dale EXHAUST FOOD(W/DULT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Ilene Receipt#
Will the applicant or fwure building occupant store or handle hazardous material HEATING UNIT(OVER 1 W,fXq li'1'U) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Croda Section 25532(a)1
0Yes ❑No VENTILATION FAN(SINGLE RFSID)
BOILER-COMP(JHPOR INB WBTID ISSUANCE DATE
Will the applicantorfuturebuildingacupmmuequipmenmrdeviceswNchemit t Ips harmonious air commudirams as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,6110 BTU) r A O D
Disvicn
� ❑yes ❑No NEW RESIDENTIAL MECH. SQ.FT. It 16 1
1 have read the hazardous materials rquirema
ems under Chapter 6.95 of the RlJ 1994
California lleahh&Safety Code,Sediuns 235(15,255J3 and 25534. Iundersmndthm
if tee building does not cuuemly have a Imam,teat ilk my respmsihility to nmify the CITY
ucc.Pnm of the reyuiremems which must bo met Prior to Issuance of a Certificate of UI• l#Llr'[fj 111
Occupancy. �..�,/./7 �
Ownerorawlmmadagend Date L. ISSUED BY: \100 F r
OFFICE