26610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2661 0
+RUILDING PROJECT IDENTIFICATIONS"
BUILDING ADDRESS: 1/�.• �' ..„ SANITARY NO. APPLICATIO
N SUBMITTAI.DA'IL
�r ^Y ONITif LOT# ��1—�
OW ERS AME: � � PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
Y
ARCHIT[CT/ENGINF,F.k: LIC NO: ADDRESS:
� wrv( ❑
CONTACT: PHONE:
QTY "ELBCTRJCPERMIT-, x gs-FEE fi d.BUILDINQ PERMIT INFO
ELECT PLUMB
PERMIT ISSUANCE �.� XLF( p
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL OB
I h703 ffrmtbati am under r p (commencing eis an ]OB DESCRIPTION
.p�'z hereby povisionsofCha mr9
¢10�y0 Section]WO)of Division 3 of the Business and Professions Code,and my license is in PANELS
<UE Licerfall re Class
effect
<, ty Date Class Lic.# UP T02W AMPS
a Date pTContractor
V 201-I0M AMPS
I-`,Z �� ARCHITECT'S DECLARATION SQ.FT.F'LOO AREA $/SQ.FT,
OOZ-O tunderstand my plans shell be used as public records. OVER IMF AMPS
FE25 SIGNS ELECTRICAL
Q` ..I Lensed Professionul sod
�Ca¢ OWNER-BUILDERDEC Contra ON SPECIAL CIRCUIT/MISC.
O W I hereby affirm that 1 am exempt from the Convector's License Lew goalie
W 3 u•m following reason(Section 7031S,Business and Professions Code:Any city or county TEMP.METER OR PULP INST.
Ran� which requires a permit to construct,alter,improve,demolish,or repair any structure
>� poor to its issuance,also requires theapplicant for such permit to file a signed statement POWER DEVICES
W EMS that he is licensed pool.uanl m the provisions of the Contractor's License Law(Chapter
p 9mencing with Sued.7000)of Division 3oflhe Business and Professions Code) SWIMMING POOL ELECTRIC
(comVALUATION
�
or that he is exempt therefrom and the basis for alleged exemption.Any violation of �� J
QY, Section]03 LS by any applicant for a permit subjects thai,micand 1.a civil paredtyof OUTLETS-SWITCHES-FIXTURES
yyy yy O net more[ham five hundred dollars(5500),
propery, yntmP Y g pense NEW RESIDENTIALELECTR _SQ.FT.
W m ❑ I,asowrk,an t t erre Ioeeswi[hwe ed finsall(Sme tem tion, STORIES IYPB CONSTRUCTION
p, will dmhework,Ceclh The Contractors
Lie a se Law does net
apply to im Business
and property
whlore Cede:The Contractors License Law does not apply to an owner of
ownu ty wyess,pdsor edthates thereon,improvements
are
such workhimselfor[hrougM1 his
however,thebuildi building
provebimpmvementsin not
eyear dad proffered Porsme.IL OCCGROUP RES.UNITS
however, theburdenf .eia is hot hedidno[buildofcompletion,theowner-
b le.). will have the burden ol'proving[het he did not build or improve for purpose of ��
sale.). TSd
❑ l as owner ofthe property,am exclusively controlling with licensed contractoreto Qg*Y.°: p y PI71v1MBINO PER LTJ: �T �`eF[EE94 FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors J Y n a x`
License Law does notapplyto an owneroflamaddy who builds ori mprovesthereon,andPERMIT ISSUANCE
who contracts for such projects with a contractors)licensed pursuant m@e Contractor's ALTER Loss. WATER(EA) �.k h f;}i�u� FEE SUMMARY � *
_ ❑ I am exempt under Sec. ,B&P C for this remen BACK FLOW PROTECT.DEVICE TSIDF.FEE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
-❑'I hereby affrm tIt have a certificate ofconsentto self-imare,macenificam of FIXTURES-PER TRAP RECEIPT#
Workers'Compeneation lnsumnce oraeedified copy lhereof(See.38W,Lab CJwhich PARK FEE Y
covere all employee's under this permit GAS-EA.SYSTEM-i INC.4 OUTLETS REJ7ElPT#
Polley# BUILDING DIVISION ES
Company - G 9- T 1,1VrA(p�) PLANCHECKFGE
❑ Certified copy is Cited
the city ,-il y 1 P
❑ Certified copy is filed with the city inspection Division. G AS 'NDUSTRGWAST6INTERCGpft)RTWI
_, t GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G F.AS TRAI!Y �, SOILS PEE
COMPENSATION INSURANCE.
(Thissec[lomneed am be complmal lftheperesit is foraneluestral do[].(SIM) S M-SANITARY-STORM .2 ENERGY FEE
idea)
I cenifythat in the performance ofthe work for which this .it is issued,Ishan W TMHEATERW/V
not employ any person in any manner so as 0 become subject to the Workers' ""' PAID
Compensation Laws of Califomia. Date WATER SYSTEMPFREATING Date Receipt
O Applicant
Z C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLAIN, SQ,FT. TOTAL:
F (n become subject to the Worker's Compemahm previsions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDIN /y
L1a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirn that here is a construction lending agency for the performance of -
U Q the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
�-t Larch's Name &
w l"r Leaders Address TY. ' TP yM ECHANICALPERMI7$`'' ^ �T? FFE" PLUMBING FEE
U I ten fy that I have read this application and stats that the above information 'v >a - T z �)i Rs
correct. l agree to comply with all city and county ordinances and and laws relating to PERMIT ISSUANCEMECHANICALF
V) building construction,and hereby anthorim representatives ofthis city to enter uponthe
V Z above-mentioned prapeny,for inspection purposes. ALTER OR ADD TO MECH, CONSTRUCTION TA
(We)agree to save,Indemnify and keep harmless the City of Cupertino against
IlabiNies,judgments,costs and expenses which may in any wayacerueagainet said City AIR HANDLING UNIT(TO 10JW CFM)
consequence of the marine 0
n 6 16 AIR HANDLING UNIT(OVER 101-m-1 �.►�+
14
Signamrc of Appi candiromosanj Date EXHAUST HOOD(WMUCT)
PAID
HAZARDOUSMATERIALSDISCLOSURE HEATING UNIT(TO IOO,WO BTU) Date Elect #
Will the applicant or future building occupant stare or handle hazardous material
as defined by the Cullman Municipal Cale,Chapter 9.12,mrd the Health and Safety HEATING UNIT(OVER I WPW BTU) TO L:
Code,Section 25532(a)Y
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR I W,oW BTU) ISSUAN E D
Will the appliiamorfumrs building by the ray equipment Quality anichemh Ir
I haznMous uir cummninan[s as defined by the Bay Area Air Quality Management BOILER 100,000 BTU)
Di=nt, JUL 211994
❑Yes ❑ H.Nc NEW RESIDENTIAL MECSQ.PT.
I have read the hazmdcus materials requirements under Chapter 6.95 of the
Califomia health&Safety Code,Scaions 25505,25533 and 25534. 1 understand that CITY fit:
occupant of g requirements
h mustnan met prior my issuance
oility Certificate
the V V
O
occupant of the rcqulmments which must be met prions Vesuwca of a Certificero of
Occupancy.
Owner or uuthonzal agent Date
TOTAL.: ISSUED BY:
OFFICE