26014 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO L. .hL RL AL PERMIT NO.
BUILDING.DIVISION APPLICATION/PERMIT PLumnwG-MecxANICAI. ^ �O I
IIIIILDIN(,PROJ ECr D)KM'IFICA'1'ION L 1
BUILDING ADDRESS:
UNIT LOT
SANITARY NO, API'LICA HUNSUBMITAL
NA F DATE
�`
OWN R. - PH CONTR/fACTOR'S NAME: LIC NO: LL
h/FiBCO y( N/C CONROLp
"IITISCf/EIJGINEFR: LIC NO: ADDRESS: ❑ �4O
CONTACT: 0A' �~ Q
Sf 4
PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG_ ELECT ALD :C
PERMITISSUANCE �� BLDG ,J�n1spl
LICENSEDCONTRnderpmSDECLARATION r9( APPLIANCES-RESIDENTIAL
pyoz Ih70stuoEnnthat m Ism licef3wuses and Ponesr...Cpda,arommen<ing with TOB DESCRIPTION
00 fall fon 7Und e f Division 3 of the Buxinces and Proreuions Code,end my license is in PANELS �s.�
t Z full force.nd,Bal.
QZ License Class �`y Lic.# UP T02W AMPS t l
ypr0.is Dart �� �r•'ys Contrac 201-IBM AMPS
ZOy'Z ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
oz�—p I.ndemm�d my plans shall be used u public records.
MW SIGNS ELECTRICAL
4 ..JJ IacenseJ Professtnnal
06E< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 moby'from Net I em exempt from the Camino.".License Law for the
'��orGn following reason.(S,cdon 7031.5.Bushels and Professions Cade:Any city ar county TEMP,METER H ST
6y J which requires a fin oth m cnnson,alar,imp ns.,demolish,or repair any structure
�T, PH"toits ismnc
ae.Win requimsthe MIlicarmfar such permiuofile saignedsatemrnt POWER DEVICE
R Go that he is licensed Pursuant m the Provisions of the Contractor's License Law(Chapter
Ip� 9(commencing with Section 7000)of Division JnftheBuiness'nd Pofesxi.m Code) WIMMINGPOO E ECTRI
se— or Nat he iseumpnhcmfrom end th<buis for the utleged exemption.Myviolnion of VALUAZ'IgN
T Section 70313 by any applicant for a permit subjects the applicant to a civil pewlry of ETS-SWITCH -FIXTUR `^ATT/
am more than Ove hundred collas($5W) "MV
W 011 ormyemployeeswithwegesutheirsolecompcnsation, NEW RESIDENIALELECIR _SQ.FT. 5 FS Cf
ty3— willdothework,'ndtheswcwno
reistinandMoroffetedforsate(Sec.7044,Busimss TYPE CONSTRU10N
and Professions Calc:The Contractor's L.icenae Law does not apply m an..all of
property who buiIas or inamwes thereon,and who does such work himself or through his
awn=Ployas,pmvided Isuchimpmvementsmenotimrndedorofferedf,W,.if. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L,asownerofthepmpny. mcxclusivelycontrectingwithli<rnsedcontnatorsa QTY. PLUMBING PERMIT FEE FLOOD ZONE APS!' ustmct the Profen(Sol.(S .7M4,Business and& Cade)no Cano Contractor's
License Lowdoes not apply loan ownerafMperty whobuildsorimprovestheoeott,and PERMIT ISSUANCE
whocantata forsuchprojects with aeon lsomms)licensed pursuant to the Comraatols
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ I ata exempt under gca ,B&P C for thin rcuon
BACK FLOW PROTECT.DEVICE S
Owner Dam SANITARY yry_
WORKMAN COMPF,NSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
k�fJrhercby affum thatlhave a<enificam of consrnno self-imure,meunificaa of SCHOOL TAX y N
r"Com tion luuance or acenifsed copy thereof(Sac.39(10,LMC.)which FIXTURES-PER TRAP r� RECEIPT'#
#ansa PARK FEE _
T aall employee's under permit. RECEIPT# N
Policy n GAS-FA.SYSTEM-1 INC.4 OUTLETS
Company BUILDING DIVISION FCFS
❑ Certified copy is herebyfamished, GAS-IA.SYSTEM-OVER4 EA)
PLANCHECK HE
Certified copy is fled with she city inspection division. GREASR/INDUSTRLWASTE IN - C
G DIN
CERTIFICATE EXEMPTION MOM WORKERS' GREASE TRAP
COMPENSATIONINSURANCE
Mis section need not becompleted ifthe permit is foromehunared dollaox(SIM) SEWER-SANITARY-STORM PRE _
m less)
l certify that in the perforrnance of the work for which this permit is issued,Ishdl WATER HEATER W/VMTA!LECTR
not employ any Person in any manner so as to become subject to the Workers' FIATR
O OCompensation Lawsnf Califonam. Data WATER SYSTEWMEATI Date Reeeiptp
Applicant — -
NOTICE TOAPPLICANT:If,after m'king this Certificate of Exemption y.a should NEWRESIDENTIAL PLMB. SQ,FT.
F' Vl become subject to the Worksev Compensation provisions ofthe labor Code.you must TOTAL:
a ; forthwith comply with such Provisions at permit shut[be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 bellby suffiran that them is a comtruction lending agency for Its,perfarmance of
U O the work far whiclytlysyerky tjg issued(Sol.3097,Civ.C.) L: ELECTRIC FEE
Lk1 Lender's Nume J\/ V/�•
O U "Mac's Address QTY. MECHANICAL PERMIT FEE PLUMBINGi
I certify that I have land this application and such,that the above informmion is
F OWa cmrrem. [ogre,to comply with all city and wunty ordinances and start laws relating to PERMIT ISSUANCE MECHANICAL ME
y building construction,and hereby authofire representatives ofthis city tocnterti the
U Z above-mentioned property forimpaction purposes. LTER OR ApD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,Coaaald expenseswhich may in any way accrue against said City AIR HANDLING UNIT(T010,000 CFM)
in comequer/see of the granting.!this permit.
/i: '.✓ r 4 —� &" AIR HANDLING UNIT(OVER 10,dX CFM)
St�gnattum of_Appl¢ant/Contmcto `•T Do� EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATMG UNIT(TO 1 W,TKKI BTU) Date Receipt p
Will the applicant or future building occupant smla or hurdle heuMousSafe,,
ei
m defined by the Cupertino Municipal Code.CheoWapter 9.12. the Health andd ,J
Sefery HEATING UNIT(OVER 1 W,f100 BN)
Cada,Section 25532(a)P
11
❑Yea 0N VENTILATION PAN(SINGLE RESIU) I
(
Will the epmus
piic' orfnturt buildingoccupent eequipmentordevittswBOILER-COMP hich emit SHP OR 100.000 BTU) ISSUANCE DATE
'Lu vmn air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.00)BTU)
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.PT, PAID
1 have read the haurdous materials requirements under Chapter 6.95 of the
C.lifomia Iiealth&Safety Code,Sectiom]5505,25533 end 25534.I undersand that JAN 2 8 1994
if the building does not currently have a tenant,that it is my mMonaibto notify the
cupant of the requirements which must he met Prior to issuance of Car iftcua of
tx<apan<y.
CITY Ur uurcnulaU
Owner m athmimd.gent Date
ISSUED BY:
OFFICE