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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUJLDIN1i - E- F.LF.C'I RICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO.
26450
HUILUINf. AUD- S�
11
^O
SANITARY NO.
APPIlGR
T10NSUBMfALDATE
OFEET
G+ 'C��/
ten
LOT#
NERS NAM 1.11(1 E: �. ��
PAX,
ONTRACfOR'S NAME: LIC NO: 7
��eN���///C
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/I—`l`
CON ROhM
�a
L
VRCIII'IECf/ENGINGER: LIC NO:
ADDRESS:
f C a#
Co CP P!yI N -
QT'Y. ELECTRIC PERMIT IEE
BUILDING PERMIT I 'FO
BLDG ELECT YL_UMIj Mme'--'\
L��fT jpO►` �L�1/�
.i�9s
V riw V Q� Za, a 7.1 6
PERMIT ISSUANCE �
LICENSED CONTRACTOR D1!CI.ARATION
I hereby a(f co that 1 nm licervwl underprovisionxof Chttpmr9 (commencing with
APPLIANCES -RESIDF.N'DAL
LOB DF.SCRIPI'ION
PANELS
UP T0210 AMPS
Section 7017S) or Division 3ol'melhnine5xond Pmlcaions CWe,andmy fieonse is in
full lot and If
ac S 7%i0 P9
1.11
W V
Corrm
Umc Contractor
:)me
- 1000 AMPS
A CHITECTS DECLARATION
1 understand my plans shall be used as public records.
OVER
OVER 1000 AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
���as `��
SIGNS ELECTRICALhiccnscvl
Professional
OWNER-BUILDER
rom he CRA'I'10N
License law for he
bertbY affirm that 1 am exempt form the Coxiom;
SPECIAL CIRCUIT'/MISC.
TEMP. METER OR I.OLI?INS
requwsom(SemI 911.115,Businoanip lve.dc inns o orcounty
�� LO�
which to ,or:Anyeity
which requires a Ocnnit w cnnxvun, ultvq impawc. Amnolinh, or rtpoir any structure
prionoitsissoanegalsoreqalrtuheopplicam forsuch permit lileasigned nmmrtent
POWER DEVICES
that he ix licensed p .... anuo the provisions of the Contractor's License Law (Chapter
9(commencing with Section 0000) orDiviaion 3 of the Business and Professions Code)
or that he is exempt dtcre(om and Ne baaisfor the ellegcd exemption. My violation ofO
Secany y applicant for a permit subjects the applicant to a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
/IS 1
C/v\`
OVH-EfS-SWITCHPS-FI%TURFS
not more than five hundred dollen ($500).
❑ 1.usownerofthepropeny,ormyemployaswithwapxasthcirsolecompensation,
NEW RESIDENTIAL ELr.CR SQ. Er.
STORIES
TYPECONSTRUCHON
will dmhework, andthe Inmate(Sec.IIHn, Business
ono CWc: The Comrunors
eConflanmintendede Lawrdo
Lew does apply In an owner of
and I•ay
h ndwho or
,olicowns lywhos, proved that mumcrcomandwho west ctf imendkhlmwlfor throughhis
cnmloycea, that acct improv dor of(crtd fwsalc. If,
arc not ear
OCCGROUP
RF_S.UNITS
ldingl r i soldwit of own
builder,
theoric
oimprove
wtheavet a burimprovement;oathwithinoneyear
foron.
builder will have me burden of proving that he did not build or improve for puryoa of
of
QTY. PLUMBING PERMIT FEE
ole.).
❑ Lea owneronhe property..meada,mAycontnningwhh Beanaea conmetonm
ElooO Zone
nPN
cnmpoet the project (Sec. 904k1, Business and Profeaions Code) The Conniscmr's
.pplyto an owner ofpropcny whoatai Jsnrimproves rM1<mon,and
PERMIT ISSUANCELiccnsclawdoesno
whocnmicisfor such pmjeets with a rontractons) licensed pursuant to the Conoaaors Law.
Licese
n1
A LTER- DRAINh VLNT-WATER (E
EEE SUMMARY
❑ am exempt under See. , 11 R P C for this mttmn
ItA U ROTIiCT'. DEVICE
OUTSIDE
OUTSIDE FEES
Y N
Owner DamRECCIPI'M
DRAINS - FLOG ROOF, AR OND"
WORKMAN COMPENSATION DECLARATION
Nlha¢by
SCHOOL. TAX Y N
aDirm thou naveacenificem o(comm�t msel6inmm, uraarrifc fish
drnken'Compcnsmion lmunnce or eccnifiW copy thereo((Sec.3800,1ab C.) ich
nXT FS- F. T P
RECF.IPI'N
PARK FEE Y N
ectsent all emploYac's under this pennil
I 'C. 4 OUTLETS 0'
RECEIPT
BUILDING DIVISION IT -ES
Policy#
Company
AS-EA.SYSTEM-OV (EA)
PLANCO[CK Ii� D O
❑ CenifedcopyiuberebyfnnixbW.vii
GRFASFJIN RL WAS' IE INERCEPTORG
I GFI.1.
a �!
❑ Ceniliodcopyisflcdwiththccityinspcctiondivision.
SE TRAP
SOLI. 'E71'
CERTIFICATE OF EXEMPTION FROM WORKS7RS'
CON PENSATION INSURANCE;
SEWER - SANITARY - STORM EA. 200FT. Vf
ET'E$�>Y .tIOLtic
(Thim xeclion need not be completed ifine permit is Into hundrWdollan(5100)
or less.)
WATER HEATER W/VENIOELECTR
a
I ccnifythm;nine perfmainceofthe work(or which,hi, permit is issued, Isell
nm employ any pcnon in any manner m as to become subjm m the Workerd
CompenationlawsofColifomiu. Date
PAID
WATER SYSTEM/IREATINGApplicemNOTICE
TO APPLICAN:If, after making this Ceniftcate of Exemption. you should
NEW RESIDENTIAL PLMB. SQ.
becomesubjeenomeWorkers Compensation provisionsorihe LuborCoda you mustf
BU1LD1CONSIRUCOON
mthwim comply withxuch provisimtsorthispermit shall bedecmul revoked
LENDING AGENCY
benby affirm mat mem is a construction lending agency for the performance ofrbe work fm which this ls.it is iaued (Sec. 309). Civ. C.)
SEE IC PheI
lO
R FEFLcrulers
NameLwsjcrs Address
QTY. MECHANICAL PERMIT FEE
N INr Tie
1 certify that I have mad this application and state that me above information is
cnrttt. ( agree m comply with ull city and county ordinances and state laws miningto
PERMIT ISSUANCE
MF.CIIAN L ELL
building mmruaion.and hereby mummiae mpresemmivex of this citym emeropmm the
above-mentioned property for inspection purposes.
ALTER OR ADO M MI CEI.
CONS'1'RUCTI TAX
(We) agrte to save, indemnify nod keep harmless the City of Cupenirm against
liuhilitics,judgmentx, conte wdcxpensex which may in any wayucc c ... inmLaiy City
AIR HANDLING UNI '1'(1010,W0 CFM)
in sonaapimce of the granting of this permit.
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD(W/DUCq
PAID
Date RCtcipt #
Signamrt pplicuMComm at
11 /ARDOUS MATERIALS DISCLOSURE
IIEATING UNIT OPO 100.000 BTU)
Will the applicant or future building occupant nom or handle havrdoaa material
as defined by the Cupcnino Municipal Core, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)'1
❑Yrs El No
IIeATING UNIT (OVER 100.000 RTU)
TOTAL:
VENTILATION FAN (SINGLE RP.SID)
Will mea licamorfutum huildingoccupan tuseequipmen t ordevices which emit
PP
I us air cortin inane ax defined by the Bay Area Air Quulit Mara ement
ts,t�t y y g
ISSUA EDATE
A / Q
BOILER- COMP(3HP OR 10),000 BTU)
BOILER-COMP(OVER 100,000 BTU)
❑ Yes ❑ No
I have read the ha>abous materials requirements under Chapter 6.95 of the
Culifnmm Health R Smcty Colo. Sections 25505, 25533 and 25534. I understand that
if the building docs not currently have a tenant, that it is my responsibility to notify the
ooccupant of the requirements which must be met prior m a is unnof u Cenificam of
ccupancy.
M
1,l1995
,
If
(✓r (N(/
EDHY:
NEW RESIDENTIAL MECH. SQ. FT.
Ownerorawborvcdogent Dam)'
\
OFFICE