26577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'D;Nx,-ELE,ERI PERMIT NO.
APPLICATION/PERMIT PLUMB NG-MECHANICAL. 5
BUILDING DIVISION BUILDING PROJECT IISENTIFICA'1'ION J
77
BUILDING ADDRESS: SANITARY NO. APPLICATIT
ION SUBMTAL DATE
/� a6s1
x {. 1 UNIT# LOT p
OWN12RS NAME: ONE: CONTRACTOR'S NAME: LIC NO: N/C CONI'ROLN
(ZaUJt4XqazRjiA.. Sze Z7
ARCIETECf/ENGINEER: LIC NO: ADDRESS: ❑
0 -11" 1 CA PX-o 4 Ak%, PAS ACTO
CONTACT: I S/QN'E: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/)1
BLDG ELECT PLUMB MECH
VVUL $S7-012Z' PERMIT ISSUANCE )
LICENSED CONTRACTOR'S DECLARATION pPpL1ANCES-RESIDBNTIAL gyp—' )OB DESCRIPTION
QWz Iherebyaffimr that l em licensed underprovisiotidChepter9(commencingwiN
tiJ02{'' Section TX10)ofDivision 3oftheBialmositannddgProfessions Code,and m licenseisin PANELSQdw
SCl7u�
b6G� Licfiallenac ClosseBect v Lic.p�ll ,✓ UP TO 200 AMPSorr \\
t0� Date AACHDEMPS
CTSDI LARATIOnorN - OVER 1000AAMPS
�r�m SQ.FT.F100A AREA 8/SQ.FT.
OY—0 1 understand my plana shall be used a9 public records.
a/ n3+t SIGNS ELECTRICAL Tg7Ii
Licensed Professional
Kd'Q
OWNER-BUILDER Inta n the CoATION SPECIAL CIRCUIT/MISC.
KOd V 1 ngherebyraa rf Se that I em exempt from the Contractor's License Law for the �9
m3my followingreason.(Section construct,
Business and improve,
professions Code:Any city structure TEMP.MISTER OR POLE INST. 1
which requires a Permit r cones the almn improve,demolish,or mash any statement
W QC) that hor e
islicensed.ralso rcquimtpmvisimsofor thesuch Commet to rile a nces
License,
La statement POWER DEVICES
W Y, p then he is licensed pursuant m the provisions of the Conwmor s Licmx Isw(Chapter
a C`y SWIMMING POOL ELECTRIC
WqM,, 9(commencingwithheaters]WU)he Division Sof the Business and.Any iota Code) VALUATION
WKm arthro70he 31.emptmeufrommf the bosisfor the
ct,alleged
mplicatto civil platian of
CZQ Section]03L5bymndredcollars $500).tsublectstheeppli<mnoecivilperWtyof OU'ILBTS-gWITCHFS-FIXNRFS l32 q� �D
0 not mtm than five hundred dollars($500). NEW RESIDENTIN,ELECM 1 S .FI'.
Po ❑ I,asownerofthepmparty,ormyemployceswithwagdaatheirsolec mpemetion, Q .0SSTORIES TYPE CONSTRUCTION
will do the work,andtheawaymis not intendedor Law
does
sale(Sec.m]094, sends
and Profession Cale:The Contractors acmra LicenIsw s not apply an owner of
property whobuildsorimproves thereor,und whodoeafuch work hitnselforthmugh his
ownemrueR
ployess,provideddent sochimprovements R not inumdedoroered fmanle.IL OCC.GROUP RES.UNITS
however.@e building or improvement is sold within one yearoftempledon,theowrar- ,q
builder will have the burden of proving that he did not build or improve for purpose of TOTAL: 7
le.).
❑ I,as ownerofthe property,aeaclusively contracting with licenscdconwctotsto QTY. PLUMBING PERMIT FEE FLOODZONE APN
m
construct the project(Sec.7W,Business and Professions Code:)The Contractor's
Licenu Luwdocs not apply loan owncrofpsuperty whobuildsar improves thereon,and PERMIT ISSUANCE Z,
who contracts for such projects withacontmetm(e)licensed Pursumtwthe Conttacto/s ALTER-DRAIN&VPM-WATER EA
License Law. ( > FEESUMMARY
❑ I ant exempt under Sec. .B&P C for Nis wan BACK FLOW PAOTIiCT.DEVICE OUT SID! 'EL
SANITARY YN
Owner Dam D. RECEIPT#
DRAINS-FLOOR.ROOF,AREA.CON
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ Ihereby Compaffirm
sa thml urance avirdiofcometnmsel(-Insure,o.acmlBcmech RECEIPI'a
FIXTURES-1'ER TRAP
Workers'Cmpl.'retian&,'his macarufidcopy Hereof(Sec.38o0.lab C.)which PARK FEE Y N
rs all employee's undenhia permit. GAS-EA.SYBTEM-1 INCA OUTLETS, RECEIPT#
policy as BUILDING DIVISION FEES
Compmy GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE ^
E3CenifMcupyalamebyfumwimed. ,0.dD
❑ Certified copy is Bled with the city inspection dicisian. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
1 z-
CERTIFICATE-OFEXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(Thier motion need not bemmpleted ifthe permit is Become hundred dollars($11310) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify tet in the performance ofthe work fm which this permit Is issued,l shall WATER HEA TER WNENT/ELECTR
not employ any person in my insurer u as to become subject to the Workers' PAID
Compmtsatim Lawaof Califomia Date WATER SYSTEMIrREATING Date Receipt#
0 z Applicant
z NOTICE'TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. /Q YY?,3 TOTAL:
become subject the Worker's Compw
cuon provisions of the Labor Code,you must
a ttWorker's 7 forthwith comply with such provisions or this permit shall be dared revoked. BUILDING IEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE D-��ISV
U�1. I hereby affirm then there is a construction lending agency for the peRortnence of
0 the work for which this permit,is eased(Sec.309),Civ.C.) TOTAL: -37.� ELECTRIC hL•G
0 — Lonlce.Name r PLUMBING FEE
F-' I<ou Icnity me QTY. MECHANICAL PLRMI'1' FEE 1 1.3
U I cantly that 1 have reed this apPlicaripn end acre But the above in(ormedon is MECHANICAL FEE 4
card.Imgree to wmply with all city and countyardmanccs end sum laws mlatingm PERMIT ISSUANCE13'I p�
I-' cn
buildingconstmetion,and hereby authorize moreentativdnfthis city tometrupan the CONSTRUCIIONTAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)ague to save,indemnify and kap barrel.the City of Capmina agdas,
Iimilities,judgmcna,v,xva nd expenses which may many way accmeagainnudd City AIR HANDLING UNIT(TO 10,000 CFM)
inranOnB of this trait, ry,9- AIR HANDLING UNIT(OVER IO.OW CFM)
Sig fAPPlicanV mmmo Data EXHAUST HOOD(W/DUCI') PAID
IIAZARUO 1 ATERIALS DISCLOSURE HEATING UNIT('TO RR"BTU) Date Receipt q
Will the applicant or future building occupant store or hmdle hanardous material
as defined by the Cupertino Municipal Cod,,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IORWU BTU) a T
Code.Section25532(o)P VENTILATION PAN(SINGLE'RESID) t
❑yes El No
BOILER-COME CHP OR IBgOpI BTU) .t, ISSUANCE DATE
an
Will the applictnrfutumbuildingoccupmt useeyuipment ordevices which emit If e i mrp
•Instrument au comaminmts as defmnd by the Bay Area Air Quality Management BOILER-COMP(OVER 100.00y BTU)
DiavicT!
❑Ycs ❑No NEW RESIDENTIAL MECH. 1 SQ.FT, ps`,?.p OCT 12 1994
1 have read the humardryua
ous materials riments under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that CI I Y
if the building does not currently have a tenant.mama try respoasibuity I ify the
UrteuYL'h(IINV
occupant of the requimmems which nmn be mer prim m issuance of a Certificate of
Occupancy.
Owner or anderiud agent Date TOTAL: ,3 ISSUED BY:
OFFIC