24942 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-FILECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PI.=IING-MECHANICAL n A (� �I n
BUILDING PROJECT IDENTIF-1CA'PION L 4 J LI L
BUILDING ADDRESS: / p p 9 Q!� SANITARYNO. A.PPL[CA111OONSUBBMHMTALDATE
/-� 5-/ J C� ��l L �� UNIT. LOT.
OWN[RSKA PHONE: CO=ACTOR'S AM LICNO: N/C CONTROL.
as: 6s��3
ARCIIIT[iCl'/IiNGINEER: LIC NO: A O bop A/1, e-3 7 /� �/� ❑
"l CONTACT: PHONE: �O QTY. ELECTRIC PERMIT C FEE BUILDING PERMIT INFO
HIM ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ I hembynffir that l am licensed under provisioner of Chapmr9(commencing with JOB DESCRIPTION
ta1I
00 Seen Division S of lire Businessud Promtions Code,and my license is in PANELS
FC W� ran force and effect vl n �jr a J�
<U15
I 'erre CF s_ _ ^ass Lica "'S� UP TO 200 NIN
H�y Contr ' 201-11100 AMPS
ARCIIITECPS 1,'ARATION OVER 1000 AMPS SQ.IT.Iq.00R AREA $/SQ.IT.
O Z—p land my plare shall be used as public records.
SIGNS ELECTRICAL
Licensed Prnfessinsed
"y OWNER-BUILDER DECLARATION SPECIAL CIRCULDMISC.
0aP— I hereby affirm that I am exempt from the Contractor's License law for the y - ■ 1
l_ ay following reason.(Section 703 L5,Businea.and Professions Code:Any city or county TEMP.METER OR POLE INST. N
k u-0; which requires a permit to construct,alter,improve,demolish,or repair any suvemre
7.W -� prior to its issuance.also requires the applicant for such permit to file a signed statement POWER DEVICES t
Wa'<0 that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter
aao� 9(commencing with Section7M)ofDivision 3 ofthe Business and Prfessions Code) SWIMMING POOLELE,,B, VALUATION
yxj_y or mad he is exempt therefrom and the basis for the alleged exemption.Any violation Of OUTLETS YATa.
F'L¢
Section 7031.5 by any applicant for a Permitsubjau the applicant m a civil penalty of IXTUR•
p ran more than five hundred dollars($500).
_� ❑ Lnsowncrof the property,ormycmployceswithwagcsaztboirsolecompcnsation, NEW RESIDENTIAL EL
E SQ.IT.
STORIES TYPE.CONSTRUCTION
will do the work,and lhe,mcomisum inamiledoroffeted far(See 9044.Business
into Professions Crede:'Me Contractor's License Law does not apply to an owner of
progeny who builds or improves thereon,and who does such work himself or @rough his
on employees,provided that such improvemro
csare not imendedoroflxonclorsale.IL OC GGROUP RES.UNITS
however,the buildingor improvement is sold within one year ofeompletion,the owner- TOTAL:
builder will have the burden of pining that be did not build to improve far purpmsc of
xalc f
❑ I,asmwnerofthe pmperty,amexdusivdy contracting with licenscJcomrncnmcs nm QTY. PLUMBING PERMIT FEE FLOODZONE APN
ommi t the project(Sec.9014,Business and Professions Cale:)The Contractors
License Lowdtes not apply manownerofpmpcnywho builds or improves thcrcoq and PERMIT ISSUANCE
wbonmtranefor such Projects with a<nnhadnrt.s)Iicenudpursumuothe Contractors ALTER (EA) FEE SUMMARY
License Law.
❑ 1 am eumpt under Sec. ,B&P C for this rcamn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
yr.^;Owner Dam RECEIPT X
v ) WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA, SCHOOLTAX Y N
r❑l lhnebyaffrm that l have.cenifemenf consent nosdf-imuro,ara ontificateof FIXTURES-PER TRAP RECFIPI'a
IWakcrs'Compensation lrurnnceoracenifed copy thereof(Sec.3800,Lab C.)which PARK FEE YN
•,covers all em I 1 GAS.FA.SYSTEM-1 INC.4OUTLETS j, poyec's under this+crit. RECEIPT.
`Policy p BUILDING DIVISION MRS
Ccr
CompanyGAS-EA.SYSTEM-OV[R 4(FA) PLANCHECK FEE
❑ Certified copy is hereby fumisheJ.
❑ Certified copy is riled with the city inspection division. GREASEANDUS1'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE.TRAP SOILS FEE
COMP17NSATION INSURANCE
(This section need root be completed iftKe permit is for one hundred dollars E$100) SEWER-SANITARY-STORM EA.loft ENERGY FEL?
M less.)
Icenify that in the perforaace of the work for which this peril is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the Workers' PAID
Cnmpereca nlawsuf Califnmi.. Date WATER SYSTEM/TREATING Dace Rmeiptp
Applicant
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ITA�E
TOTAL:
r V) become subjeOmde Wmkers Compensation provisions.(,he Labor Code,you must
C4 > forthwith comply with such provisions or this KMMLdiall he deemed revoked. E
ped, Q CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is a communion lending agency for the perfor.nce of
U O the work far which this pemtil is issued(Sec.JfWy,Civ.C.) '1'O A iE
Lender's Name
VLcnder's Address QTY. MECHANICAL PERMIT FEE FEEI certify that 1 have mail this application and statetha the above information is
correct.Lgreemcamplywithallcity.rod counryoNinunces endameluwsrelminm PERMIT'ISSUANCE L FEEbuilding construction..nd hereby omhoriu representatves ofthis city Inciter upon the
Zabove-mentioned property for inspection purposes. ALTER OR ADD TO MECH. IONTAX(We)agree to save,indemnify and keep harlesx Ne Cityof Cupertino againstiabilibinijudg ts,cmts nndexpeases which may innny wey againt said City AIR HANDLING UNIT(TO 10,(100 CEM)
In onscqucnw f gmming finis ailZAIR HANDLING UNIT(OVER INpCEM)
SlgnalurcofApphcant/Comranor / Date E%HAUSTHOOD(W/DUCpMATERIALS mmLOSURE HEATING UNIT(TO IW,OW BTU) am Receiptp
Will the applicant m future building occupant store to andhandlethe
hazardous a material
as de.See by,he Cupertino Municipal Cede,Chapter 9.12,and the Hwl@ and Safety HEATING UNIT(OVER IW.g10 BTU) TkV
Cede.Sceti O Ye5J2(a)? 11 No VENTILATION FAN(SINGLE RESIO) �
.4• Will(air colicwmr is as building by the ay Area Air Quality
cs Management eat
BOILER-COMP(31 IT OR 100,001)B'I'U) ISSUANCE DATE
Ebwmdous air conuminants az defined by the Bay Area Air Quality Management
Disricl? BOILER-COMP(OVER 100,000 BTU) PAID
1. ❑Yes ❑No NEW RESIDENTIAL MECH SQ.ET.
I have read the haatdou.s marecial,re APR ' 1 1993
}�` quircmems sneer Clup¢r 6.95 of the
California Health&Safety Ede,Sections 25505,8533 and 25534, I understand that
if the building does not currently have a tenant.that it is my msponsibility to men the Clrr-u�
Occupant of dace requirementswhich mist be met pear to issuance of a Ccnificate of
ULMN I IJr
prey.
Owner M onthnrmed agent Dae
TOTAL: JISSUED BY:
OFFICE