26326APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B aDl c.-LhLcl RACAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PR(3dEcT IDENTIFICATION
PERMIT No,
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BUILDING ADDRESS:
SANITARY NO.
APPLICNFIONSUBMHTALDATE
7.4 i/ UNIT # LOT#
^f�laS
V
WN S AME: PIi
CONTRACTOR'S LIC NO:
NIC
❑
CONTROL#
n
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IARCH sCPHNGINEER: LIC NO:
ADDRESS:
CONTACP: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT 'VMEC 11
PERMIT ISSUANCE
❑ E
LICENSED CONTRACT'OR'S DECLARATION
hereby officer that am licensed underprovisionaof Cliapter9 (commencingwith
APPLIANCESRESIDENTIALI
J Section 7(1!10) of Division 3 of the Business and Professions Code, and my license is in
full force and effort.
tl License Cl ass on
Dam Contractor
PANELS
UP T02W AMPS
201 - 1000A MIPS
ARC] UTECT'S DECLARATION
I understand my plans shell be used as public resounds.
OVER 1000 AMPS
SQ. IT. FLOOR AREA $/SQ. FT.
1
SIGNS ELECTRICAL
2 Licensed Professional
E OWNER -BUILDER DECLARATION
I hereby tha I am exempt from the CommusCs License Law for @e
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES l
reason. (Se
Jfallowing ims cond In 7031.5. Business and Profusions Cade: Any city.,samenury
which requires issuance, permit re wnsmse, aller,pplic nt forsu demolish, urea siig any swment
p ArmorsLicese Lad(Chapter
oslcensedpursuntto
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that hor ethevisiosofthe Co
4 that he fecnthe Contractors License Law
//
with Suamtolhepmviasision
Division Sofllecid BusinessandProfusions Cod e)
sionsC Curb)
9(commencing isxempt therefrom
S refrom and
oothat hecima7 is exempt the basis for the is hedexamplon. civiny 1p roily of
- Sxtion than byanyapplicantforapermit sublecu the applicantmacivil penalty of
Qn n than five hundred dollars ($500).
o I,asowoerofthepropcnyormyemployceswith wageastheirsolecumpcnsation,
will the work, anA the stme,urc isnotimendeJ arolxertdforsale (SecJW4, Business
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPECONSTRUCION
and Pro sionsCude: The Commdnr s License Law does not apply to an owner of
Property who builds or improves thereon,and whodoessuch work met through his
wn employees, providedthet suchimprovcmenmare notimenJedundfereJ le, If.
however, the building m impmvemem is .[it within arm yearefcomplarim, the owner-
builder will have the burden of proving that be did not build or improve for purpose of
OCC.GROUP
RES. UNITS
TOTAL'
,de.).
❑ 1, as owner ofthe propeny, um exclusively contracting with licensed contractors to
QTY' PLUMBING PERMIT FEE
fTOODZONE
APN
construct the project (Sec. 7044, Business and Profusions Code:) The Contractor's
PERMIT ISSUANCE
License Law dues nnl apply loe,t ownerofproperty who builds orimpmves thereon.end
who contmcu fur' such projects with a conimnor(s) licensed pamuamuo the Contmetoes
License Law.
❑ I sort exempt under Sec. , B & P C for this reason
ALTER - DRAIN & VENT - WATER EiA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
Owner Dam
DRAINS- FLOOR. ROOF. AREA, COND.
SANITARY Y_N
RECEIPT#
WORKMAN COMPENSATION DECLARATION
' ❑ Ihercby affirm the,lhaveaccnifcmc ofamsem msdf-insum. ora ccrifcam of
Workm'Compensation Insurance ora certified copy thoomf(Sce. 3100, Lab C.) which
covers all employec'x under this proton,
Policy #
SCHOOLTAX Y N
RECEIPfp
FIXTURES TRAP
PARK FEE Y_N
RECEIPT p
GAS - EA. SYSTEM -I INC.4 OUTLETS
BUILDING DIVISION FEES
Company
GAS
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Certified copy is hereby famished.
FEE
❑ CcnilieJ copy is flet with the city inspeainn division.
GREASFANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CER'T'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS ITE
(Thisttctionaced notbecompleted ifthepermit isfsrosehundreddollars($100)
in line,)
SEWER -SANITARY- STORM EA. 2150FT.
ENERGY FEE
Icmify the, in the perfmarromeofthe work for which this permit is issued. Idol
not employ any para,, in any manner s as tat become subject m the Workers'
Compensation Lowsof California. Dates
Applicant
WATER HEATER WNVE /ELECTR
PAID .
Use Rereipt#
WATER SYSTEMIVREATING
NOTICE TO APPLICANT: If, after making this Certificate of Eacmption, you should
Nsome subject in the Worker's Compensation provisions of the Labor Cade, you must
forthwith comply with such provisions or this Permit shop be deemed revoked.
NEW RESIDENTIAL PLM B. SQ. PT.
TOTAL:
BUILDING FEE
CONSTRUCTON LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
SEISMIC FEE
ELECTRIC FEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 unify that 1 have tend tibia application and sum that the above informations is
PERMIT ISSUANCE
MECHANICAL FEE
record I agree In comply with all city and county ordinances and state laws relating to
buildingeonsuuction, and hereby authorize ¢pmsmativen of this city toenter upon the
oMrvno calioned property for inspection purpose.
emnify and keep harmless the City of Cupedino against
Iiubild expenus which may in any way a< eager said City
cog of this Permit.
AlApp
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
ATR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,gp CFAs)ctor
Dae
EXHAUST HU0D(W/DUCD
PAID
HEATING UNIT(TO 100,000 BTU)
lARDOUS MATERIALS DISCLOSURE
Willthcapplic t connote building occupant store or handle haccadous matefal
Dae Receipt#
TOT N.
as def u d by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25132(a)?
HEATING UNIT (OVER 100.0110 BTU)
VENTILATION FAN (SINGLE RESID)
CI Year 0 N
Will the applicant
conta moots as building by the Bay Areequa Aen Quality
hazardous air contaminants as define) by the Bay Arca Air Quality Management
Management
District?
BOILER -COMP (3HP OR 14,000 BTU)
BOILER - COMP (OVER 1 W,pq BTU)
ISSUANCE DATE,
^
0./
❑ Yes ❑ No
I have rend the horrendous materials requimmcn s under Chapter 6.95 of the
Califomla Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand that
Hthe building does not wrt only have a tenant. That it is my responsibility to notify the
occupant of the requirements which must be'net prior to issuance of a Cenifice,e of
Occupancy.
APR 28 1994
^
V// Y yr sur
Cry ry
BY:
NEW RESIDENTIAL MECII. SQ.IT.
Owner or uuthtmuJ agent Date
TOTAL: ISSUED
(1CCIl�C
VIrIVL