24912APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC'I'RICA],
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION PROJECT O)EN'ITFICATION
PERMIT NO.
�i �I i�'I �i
G 4 J 1 L
BUILDING nUDRF:55: r '
SANITARY NO.
APPLICATION SUBMITTAL DATE
('
9� J UNIT# LOT
OWNERS NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONTROL#
I CHITECf/ENGINFF-R: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BL G ELECT PLUMB MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l on licensed under provisions of Chaper9(commencing with
Section 7")of Division 3 of the Business and Professions Code. and my license is in
fill Por« and <-i. /f/
p Licenx ass Licp�saa L
Date Cntamcmr 4.G �6//.�
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
$
/J D
C/� 44467 A~
PANELS
UP T020BAMPS
201 - 1(IW AMPS
ARCHITECTS D LARATION
I understand my plans shall be used m public records.
OVER mOrOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Profe.+sirnal
OWNER- exempt FR DECLARATION
I hereby affirm that 1 am exempt the Contmnu License Ism for the
SPECIAL CIRCUIT'/MISC.
TEMP. ME'I'F.R OR POLEINS"1'.
POWER DEVICES
,, an
o
Professionsh, orranycity ouniunty
Eglowingmosnn.(Scit,.arm,mmliusines improve, repair any sweem
which n:yuhes n permit to comsilbe Wmq improve,h permit t file
E
priorinitsissuance,rsorcqui the provisions
forsuch Commencer Lice signed (Chaptertatement
licensed pm Ifsprovisionsdohs Ce
that9(c
suis
Sectionnt
9(crmmencing with Section 7") of Division Sof the Business end l'rofusionsCode)
Busine's and Professions Code)
n or the he is exempnherefrom and the basis farina alleged exemption. Any violation of
^ Section 7031.S by any applicant for a permit subjae the applicant to a civil penalty of
= not more than five hundred dollars ($5W).
as properly, ormy employees with wages as their sole compensomr,
othe w rk, anhe 1
Professions, aide Business
int ended orofferedfmsalepply
SWIMMING PoOI. ELECTRIC
VALUATION
7J/rD.
/
OUTLETS - SWITCHES -FIXTURES
NEW RESIDENTIAL ELEM S .PT.
Qwill
STORES
ONSTRUCTION❑
The Comisnot
and Prof<•ssiom Code: The Contmcuors Licenx Ww dces mooapply to an owner of
1.am
property who buildsmimproves themon, and whodcessuch work himselfor though hisemployees,pmvidcdthatsuchimprovcmentsurenoiintendedorof(erediorsale.
rR
If,OCC
GROUPFS.
UNIlS
however, the buildingor improvement is sold within one yearofcomplelion, the owner-
builder will have the burden of proving that he did nil build or improve for purpose of
TOTAL:
QTY. PLUMBING PERMIT FEE
sale.).
❑ I, as ownero(the property, am exclusively contracting with licensed contractors m
19AODLON[ APN
rnsmmn the project (Sec. 7044, Business and Professions Code:)'Me Crntmcmrs
License Lawdcee not aPply loan ownumoTrrpery, whobaildsrrimproves ficrern.nnd
PERMIT ISSUANCE
who cataracts For.wch projects with a r onamelons) licensed pursuant m the CnnVaclor's
Lic<rvx Use.
❑ 1 em exempt unMr Sec. B & P C for his reason
ALTER - DRAIN & VENT- WATER EA)MSANIFARY
FEE SUMMARY
BACK FLOW PROTECT. DEVICEOUTSIDE
FEES
YNOwner
Dale
DRAINS- FLOOR. ROOF, AREA, COND.RECEIPT#
FIXTURES-PER'1'RAPRECEIPT'#Workers'Compcoonion
WORKMAN COMPENSATION DECLARATION
that lhuvcaanifcamofcnnumloself-insure. oracenifmcaerf
lnsuraneeoracerlDedenpythereof(Sec. 3g00.LabC.) which
au ear �3GAS
Policy N
YN_erebyaffirm
y ryrs
T#
-13A. SYSTEM -I INC. 4 WTLLTSRF,CFR
DING DIVISION FEIS
Company / It a
GAS - EA. SYSTEM -OVER 4 (EA)
❑ CCyo�fied copy is hereby famished.
PLANCHECK FET?
BR Cenifed copy is filed with the city inspection division.
GREASEpNDUSTRL WASTE INTERCEPTOR
GRADING ItiE
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GREASE. TRAP
SOILS FEE
(Thisseclion ncedumbecomplmcd ifthepeountis for one hundred dollurs($I)J)
or .)
less
SEWER - SANITARY - STORM EA.]OOFT.
ENERGY FEE
I certify that in the Performance of the work Por which this permit is iwued,ISM1uII
nm employ any person in any manner so as to become subject to the Worker
CCraranldonlawsof Califomia. Dale
mp
WATER IIEAS'ER W/VENT/ELIiC1R
PAID
Date Receipt
WATER SY$TEMEDItEATING
NOTICE TO APPLICANT: If,:Jen making this Cmificaeof Exemption. you should
become subject m the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall at deemed revoked.
NEW RESIDENTIAL PLMB. SQ. IT.
TOTAL:
BUILDING FEE
B�
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herby affirm that them is i construction (Sec, 3 lending agency for the performance of
the wok For wbicb this permit is issued (Sec, 309), Civ. CJ
landds Name
TOTAL:
ELECTRIC FEE
Tender's Address
I certify that I have mad this application and state that the above information is
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMI"I'ISSUANCE
MECHANICAL FEE
reel. Iagree to comply with all city and county ordinances and stale lows relom,to
building construction, end hereby authorize representativesof Nis city to enter upon the
abtwe-mentioned pmpeny for inspection purposes .
(Wc) agree,, save, Indenmify unit keep harmless the City of Cupertino against
Iiabililies,judgmenos, costs and expenses which may in any way aceme against said City
in consequence of the granting of this permit.
ALTER OR ADD TO MSCI
CONSTRUCTION TAX
AIR HANDLING UNIT OIQUMICFM)
AIR HANDLING (OVER O."CFM)
Stgnamre of ApplennVCrmmcmr Dam
EXHAUST D(W/DU
// 87J
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building occupant alum rr material
haealth
'G UNIT (TO IW, U
PAID
Data Rscipt#
TOTAL:
asdefinedfythe andthandle
a d Sura
32(a)?nn Municipal Code, Chapter 9.12, and the Health and Safety
Coda Section 25532(a)?r
BATING UNIT'( ,Opt
VI: ILATIO F (SI RISID)
El Yea 011.�
Will lheapplicamrrfumm buildm cupum usenquipmemordevices whichemit
'hazardous air conmm oma s as de 1 by the Bay Area Air Quality Management
Diatdari
BOIL -COM 3 O Ip0,0I10 )
ISSUp Nf�' DATE
Cf g 8 �i
4-' P 7 ll4AA
BOILER- OMP (OVER I W, TU)
❑ Yes No
NEW RFSI IAL MECH SQ. PT.
I have wad the fazuoksualCast, Sections 550mcp5,2 533 under Charmer ma 5.95 of the
Califomia Ileulth &�FF m ety Cade, Sections 25505, 255]3 and 2553yyy4. 1 understand That
Ocheancy. l ,.C,mtm,nt, In smYr9gyo' 'ray me
Occupant at 11 faire is hiusod t t a m i a of a Cenlficate of
o«alwn<y. q,
NOV - 9 1994
CITY ter �.,renluvU
Owner., Offiamiealtigern Dam
TOTAL: ISSUED
BY: J
-I*
November 7, 1994
City of Cupertino; Building Division
10300 Torre Avenue
Cupertino, CA
To whom it may concern:
I am assigning Bob Gere, Iviasonry C011tractor to take over the
chimney replacement job at my home at 22117 Clearcreek Court.
The permit number is 27241.
Sincerely,
Terry Pilice
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