24853APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO.
/\ A /1 r fir
L 4 VX J V[
BUILDING ADDRESS: I
SAITARY NO.
NIC
APPLICATION SUBMMAL DATb
OWNERS NAME PHONE�:
C ACTOR'S NAME' LIC NO:
��-V
CONTROL#
ARCHITEC'UENGINEER: LIC NO
^DRESS:
CONTACT: rxor+e:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
.DG ELECT PLUMB MECH
PERMIT ISSUANCE `
❑
LICENSEDal CONTRACTOR'SDECLARATION
L IM1ereby of
fDiviha03 Ofth Business and ProfesioCM1apler9(cammencingwidh
C fall funeirind)of Division Jof me Business and Professions C=9(,`d mylicaroacoa
JfullforceanA dfecd.
y Licenu Clan Lic.#
Dwe Contractor
APPLIANCES - RESIDENTIAL
PANELS
UP T02W AMPS
OBI ES Ik'TJpN
201 - 1000 AMPS
n
Z ARCHITECTS DECLARATION
1 understand my pl... hall be used as public recor}s.
y
SV.IT. FL(�gpgEA (
Nth) Bn"p
V
Ir
II`../II
TER
S/SQ. IT.
OVER IOW AMPS
SIGNS ELECTRICAL
jLicensed Profesvonal
OWNER -exempt IRDEC Contra ON
1 hereby affirm that 1 am exempt from the Contmwors License Law for the
SPECIAL CIRCUIT/MISC,
TEMP. METER OR PoLT:INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
v followingreason. (Section ciawar Business and Professions Code: Any city orcounty
re
which quires a permit to cotawn, ober. intprovu, demolish, or rcpwr any sdmnure
S Thai he isissuance,nosoreonot Ne.Warantfohe Common, License
Licenu La ions Co ter
La (Chapter
Thai M1c is nci ng with Section ") of Division of Ce Business
i 9(cnmmeis exemlthSeefivanndThe Division Sof theBusiness ant,AnyvunsCode)
N octhwhcisexempt Ncrefromand Nc baspconilorbjeallegedexcmption. Any violation of
an,applicantdollforopermit.vuhjens 1M applicant do acivil penwty of
Sectione Than five
not more than five he pm,ny,monars SSW).
❑ othownk of Nehestmetnow is n cmployces endedwifferedortalei(sole70al Easiness
fortale 44,Business
_ will dothewons
VAI UAIi(}N
72
OUTLETS IES- FIXTURES
NEW RESIDENTIALELECTR S Q. FT.
STORIES
—TYPE CONSTRUCTION
Code to
The Contractor's
and professions Code: The Contractors Licenu
License Lao, does not apply o an owner of
owes i
pmpery who builds err improves thcmm, and who docs such work hitredfor through his
,m,thebuildingriprovehlmprovcmcrosam trot eardcdmoffercd forsala R',
f.
err improvementissold within One year of comp thrower
OCC GROUT'
RES.UNITS
bWwcvct,thehanding
builder will have the burden of proving Nm M did not build or improve for purpose of
for
sale.).
licensed tnmemrsm
❑ Lesoe prrneNe property, endusis and Professions
Ammo the project (Sec. 904 Boniness and fcwions The Contractors
QTY' PLUMBING PERMIT FEC
ILOOD LONE
APN
yr
Licwho, l.awdoesnmupplyroanownerof
o orom) toles Nereon,and
PERMIT ISSUANCE
ti Porsuch projatx wiN a conuactot(s) licensed punuam to the Cnmrunor'v
crop sywhoscd puouant
whence
FEE SUMMARY
hicenu Law.
La
❑ I am exempt under Sec. , B & p C for this reamer
ALTER - DRAIN &VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
OUTSIDF FEES
YN
OwnerSANITARY
Date
WORKMAN COMPENSATION DECLARATION
'❑ co., Coywlimtthulasuniu oraceam of copy thersof(Snmre,o, Lab C.) which
Wod.ery Compense's nlnsursscermit. ified ropy thereof (Sec.38W, Lab C.) which
colics all employee's under this Permit.
Policy #
DRAINS -FLOOR, ROOF, AREA, COND.
RECEIPT#
SCHOOLTAX YN
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y_N
RDC
GAS - W. SYSTEM- INC. 4 0UTLETg
BUILDING DIVISION FfiGs
Company
GAS - E A.SYSTEM "OVER 4(EA)
❑ CmifieJ copy is hereby famished.
PLANCHHCK FF,E 71
❑ Canifietl copy is fled with the city inspection division.
GRADING FEET l.J
GREASMNDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
REASGTRAP
SOILS F
FEE
(This section need not be completed ifthe permit is turner, hundred dollars(SIM)
r las)
SEWER - SANITARY - STORM EA. 2WF7.
LNERGY PEE
I certify that in Ne perfomance of the work for which This per mit 11 Mind, I hall
not employ any Person in any mannerser as to become subject to the Workers
Compensation Lawsof Califomit. Date
Applicant
WATER HEATER W/VENDF-LECTR
PAID
Date Receipt#
WATER SYSTEM/I'REAT'ING
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
become subject wife Werkee-Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMIL SQ. FT,
TOTAL:
fnnhwith comply - 0i such provisions err dive permit shall be deemed revoker.
BUILDING M.E.
CONS "I RUCTION LENDING AGENCY
1 hereby affirm Nat Them is n construction lending agency for the performance Of
the work for which this permit is issued (S,a. 3099, Civ. C.I
Linda's Name
SEISMIC FEE
11
ELECT RIC PEE
Lendds Address
QTY. MECHANICAL PERMIT FEE
PLUMBINGFEE
I certify thud I have read this application and stem that The above information is
PERMIT ISSUANCE
correct. I agree to comply with all city and county Ordinances and.uhlia laws relating to
building construction. and hereby authonae representatives of thiscity to enter upon the
above-memioncd prn(xny for inslmnion purposes.
liabilili judgi is. costs and expenses which ma in anyway accrue against said City
Wme t e) it to save, indemnify and keep harmless Ne City of Cupertino against
incense go p11
MECHANICAL F'EE
ALTER OR ADD TO MECH,
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10,"CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
? 1
J
Signaturcof App canVContmctor D tc
EXHAUST HOOD (W/DUCI)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or home building occupant stem or handle hamrdo to material
as definuJ by thu Cupertino Municipal Code. Chapter 9.12, and the Hea1N and Safety
Code, Section 25532(x)?
PAID
Date Rcecipd#
I(EATING UNI T(TO IW.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
❑ Yes ❑ No
Will Ncapplicamor fnumbulldingoecu oat use
p cquipmem ordevics which emit
hamrdons air contaminants as defined by it,, Bay Arca Air Quality Management
Dannct2
❑ Yes ❑ No
BOILER- COMP CHP OR 100.000BTU)
ISSUANCE DATE
P 9
BOILER IM,,T, BTU)
NEW RESIDENTIAI, MECH. SQ, FT.
1 have tend the hazardous materials rtquimmems under Chapter 6.95 of the
Califumia Health & Safety Code, Sections 25505, 25533 and 25534. I understand for
if the building does not cumadnt
y have a mma, that it is my rcspnnsibility to notify the
°ecupwn of the requirements which must be met m mprior issuance of Car, O,,he Of
"a"m`y
MAR 12 1993
CI I T Ur I 111Iry
BY :
Owne "I won brier agent owe
TOTAL:ISSUI3D
OFFICE