26582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V
QiLGIRUV.ECE1TRICA I PERMITNO. 26582
CITY OF CUPERTINO PLUMBING-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDFNI'IFICATION
BUILDING ADDRESS: y �I] SANITARY NO. APN,ICAaTTIIO�NSUBMIITTTALDATE
2A9�D {`(7 `L. UNITif OIL 7 LOT al G�I1pJ
OWNERSNAME: PHONE: CONTRACfOR'S NAME: LICNO:
SaAS' IA'T ��� - N/C CONTROI.p
ARCIIHLC'UIiNGINB[iR: LIC NO: ADDRESS:
s ❑
I-11 f lQ( l bf� PV 6.QAcO Al:fb
CONTACT - 'k,� HONE dU1LUING PERMIT INFO
tA'&I NG VoItL ea_ ••� 1 I Q'I'Y. ELECTRIC PERMIT FEF.
(�..� i�/p^^// BLDG ELECT' PLUMB MECH
Qlyy PERMIT ISSUANCE D1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT LM,
QCZ Ihereby affirm that l am licenadunder provisions of Chapla9(commmcingwilh ION DESCRIPTION
F+00 Section 70B0of Division 3efdreBusiness enitPmfessionsC and my license is in PANELS Sip
y�IF full force and effect. Irl+' AJ
QFyW L.a. cClass Limp 2 UP 70200 AMPS V _�
y=y Oma lA AAAA Contlnnor 2ol-IIXp AMPS SQ.FT.FLOOR AREA S/SQ.M.
G Oy_? CfI1TECTS DECLARATION OVER 1001 AMPS
pp 1 understand my plans shall be used as public records.
y FeL u1 SIGNS ELECTRICAL c,
Q,WC� Licensed Professional a 3 .
p y� OWNER-BUILDER DECLARATION SPECIAL CIRCUITJMISC.
XOyU 1 hereby of.that 1 am exempt from the Commerce.,License Law for the r
W33Hfollowing reason. Section?031.5,Business and Professions Code:An cit n TEMP.METER OR POLB INST. �� -L!1
¢ 8 F Y city county 1
Mn0J which regainsnprofit recores the her,improve,demolish,orrepair any structure -
f .0 that he
issuance,also pursuant to the
the npplimmfthe Commmiuo Bleasigndsmmmcm POWER DEVICES
y M,, 9forsa encemedpunction th0)of provisionsofthe Conuecmrs Lice nu Law(ChapterCode)
SWIMMING POOL ELECTRIC
dM,,K 9(c,mmcncing with Section 900(11 of Division Jofthe Business and Professions Cale) VALUATION
CZQ ,,that he is exempt thercfmmand the breis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTURES 4� 1 Ln 2
i Section 9031.5 by any applicant for a permit subjects lie applicant to a civil penahy of lV `T
C of moa Nvn five hundred dollen(tSlq). NEWRESIDENTIALELEC'1'R SQ.PT. ton - STORMS TYPE CONSTRUCTION
WC 2 ❑ I,asownerofthepmpcny,ormyemployeeswiWwagnaathcirsolccompensation,
S3� will do the work,and the structure ism,intended moffered mrmm(Sec.9044,Business
and Professions Code:The Contractor's License Low does not apply to an owner of
pmpmywhobuildsorimpmvev ucon,andwhodees such work himselforthroughhia
wnemployecs,providedthanuch impmvcmentsare not interdcdoroffcmd forsale.If,
OCC GROUP RES.UNITS
however,Nebuildingorimpmvcmentissoldwithinmtyeaofcompletion,theowner- TOTAL: (-,i
builder,will have the burden of pmvlmg that he did not build air improve for purpose of
Il QTY. PLUMBING PERMIT FEFtoOD_ZONE APN
❑ I,mnwnerufthe propeny,um exdmivelycontening with littmd c,nhacmnm
construct the project(Sec.7044,Business and Professions Code)The Cmustrun"s
License law does not epplytoan ownerofpmpenywhobuilds,rimprovn thereon.end PERMIT ISSUANCE
whocontrnna f,rsach pchon withacommeam(s)licensed fammantm Ne Connector'sK
ALTER-DRAIN&VENT-WATP.R FA
License Law. B ) FEE SUMMARY
❑ I nm exempt under Sec. .B&P C for this rcmon BACK FLOW PROTECT.DEVICE OUT SIDE LL
SANITARY Y N
OwnerDate URAINS-FLOOR,ROOF.AREA.COND. HEC1?IPI'p
WORKMAN COMPENSA'f10NDECLARATION SCHOOLTAX Y N
❑ Thereby affirm thatl heveacertificnte of c,nsenl mself-insure.ora cenifi<am of FIXTURES-PERTRAP RECEIPTp
Wmkers Compensation Insurance orecenifid copy thereof(Scc.3gW,lab CJ which PARK FEE YN
covers all employes s under this permin. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy p BUILDING DIVISION F
Corrpmy GAS-EA.SYSTEM-OVER 4 T/H PLANCHECK FEE eat
ElCmifiedcopy is hereby famished. W-`o
❑ Certified ropy is filed with hhecity inspection division. GREASWINDUS'IRL WASTE INTERCEPTOR GRADING FEE nn
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASET'RAP SOILS HE
COMPENSATION INSURANCE
(This auction recd not be completed ifthe permit is for one hundrd dollars(SI00 SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I cenify that in the perfonnancc of Ne work for which this pemsit is isaued,lahall WATER HEATER W/VENTICLECIR
.or employ any person in any manner ao as m become subject m the Workers PAID
COmpensationlawsuf California. Date WATER SYSTEM/IREATING Dam Receiptp
Q z Applicant
O NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENT IAL PLMB. SQ.Fr. . 10 TOTAL:
becomesubject mdse Wmkds Compensation pruvmons oft he labor Code,you must BUILDIN O�6s
forthwith comply with such provisions or this pe.it shall h,deemed revoked.
W Q CONSTRUCTIONLENDINGAGENCY SEISMIC 17EL Y.D
1 hereby affirm that them is a conawcdon lending agency for the perfirs ,of
C) O�+ the work for which his permit is issued(Sec.3097,Civ.C.) TOTAL: �a ELECTRIC FEE
D- r Lender's Name PLUMBING FE
Lenders Address QTY. MECHANICAL PERMIT FE8
WI cenify that I have mod this application and sham that the above information is `� MECHANICAL.FE
>v correct.I agree to comply with sprit,and county ordinances and state laws relating to PERMIT ISSUANCE "1Zavy 1.
(/j buildingconstruction.and hereby euthoriu reprtsenmtivn of thisciny mems upon the CON50RUCION TA
V zabove-mrntimd property for impecaon purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep humins the City of Cupertino against
liabilities,judgmcrn.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO III,"CPM)
fthe grenIin to pe it. �I A AIR HANDLING UNIT(OVER 10,000 CFM)
u .a,Ceo g ryt
Signarme,f Applicant/ nourir — Date EXHAUST IIOOD(W/DUCry PAID
HAZARDOUS MATE
HEATING UNIT(TO 100,000 BTU) Date Reaeimp
RIALS DISCLOSURE
Will the applicant or future building amupartdcme orhaidlemosrdom material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as definod by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safety
Code,Section 25532p)P VENTILATION PAN(SINGLE RESID)
13 Yea 11 No
ISSUANCE DATE
Will Neapplicantor future building acupantuse equipmmnwrdeviceawhwhemit BOILER-COMP(31IP O0.1W,000 BTU) n
hmmm
dous air coamimnn ex defined by me Buy Area Air Quality Management BOILER-COMP(OVER 101.100 BTU) 1�
District?
❑Yea ❑No NEW RESIDENTIAL MECH. Sq n. 1.�0 a NO V 3 1994
1 have read the h:mard.m materials re9uiremems under Chapter 6.95 of the IV/ �t 17
California He dr&Safety Code.Sections 25505,25533 and 25534. I understand the
if the building does not raiment],have.teram hearing.has ih is my res,matbilitycraft, CITY
t,Ne CITY
Uh (�UptHI
rocupam of the nil uiremenn which must h met prior to issuance of a Ccmficwc of -' - /NO
Occupancy. �//\���y//�����///►��/
Owner or authorized agent Data TOTAL: �/. ISSUED BY:
OFFICE