27084 CITY OF CUPERTINO
INSPECTION DIVISION
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO .1mom-ELI:cTR7 PERMITNO. 0
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
89
BUILDING'ADDRESS: QQ kp SANITARY NO. APPP/iLICATIONSUBMfITALDAH
UNIT LOT It
OWNERS NAME PHONE: CONT'RACTOR'S NAME: LIC NO:
7 31 '4r S G TROL#
a �• T i NIC CON
RCHI'IECI'/ENGIN LIC NO: ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l PERMIT ISSUANCE �Z QQ � f4I
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL w
pyz Ihereby affirm that l am licensed undcrprovisionsof Chapter9(commencing with JOB DESCRIPTION
FJC0 Section 9000).(Division 3 mite Business and Pmfcssions Codaand my license is in PANELS
�U� full force and effect. �/
L Zpl License C�la�xj-y —Lie.# v&:1 ,1011 UP T0200 AMPS l
yQy Dale�J�fi�Conuacior 201-1000AMPS
Z O,z ARCHITECTS DECLARATION OVER IOOpAMPS SQ.FT.FLOOR AREA S/SQ.FT.
o z—O I underaund mY plana shall be used as puhli.record,.
F=F w SIGNS ELECTRICAL
Qyf,,j Licensed Prnfteocarll
C
M< OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
KOyF 1 hereby union that 1 am exempt from the Gonias Cs License Law farco the
m'3 y following uiaeon.(Section 7031.5,Business and Professions Cods:Any city structure TEMP.METER OR POLE INST.
y; which its requires n eenlso re conswm.alter,improve,demolish,fi repair any amuctme
�tisY� that hoitsissuance.alsont to the
the visiosofor thesuch Copemuuo License
Use tummenr POWER DEVICES
pz
that he is licensed pursuant th<provisions of the Conuxmrs Licerrse law(Chapter
dkoW 9(Commencing with Section 7000)of Division 3 aides Business and Professions Code) SWIMMING POOL FIECTRIC VALUA'[IOIb
or Nat he is exempt therefrom end the basis for the alleged exemption.Anyviolatim.f l��t'��J
FZa Senion 7031.5 by any applicant for u permit subjects the applicant m a civil pendity of OUTLETS-SWITCHES-FIXTURES 3wD� 3 J V
not mors Nan five hundred J.Ilram($500).
C�o ❑ I.asownerofNepmpnXmmyemployeeawiNwarswNeirwlecompenxuon, NEW'RESIDENTIALELECIR _SQ.FT, STORIES TYPE CONSTRUCTION
y,3m will do the work,and the structure is nm imendeduroffeted for safe(Sec.7046.Business
and Professions Code:The Contractors License law does not apply to an owner of
property who bui I ds or improves thereon,and who does suc h work N nexl f or through his
son employees,Provided that such improvememsminot imendedoroffered forxle.If, I OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL: SQA
builder will have The burden of proving that he did not build or improve for purpose of
sale.).
❑ I.usownerofthepropcny,antexcluxivelycontrwtingwiNlicensW n=ctm to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the poise,(Sea 7046,Business and Professions Code:)The Contractors
License Law does not apply to an owner.fpropeny who builds in improves thereon,and PERMIT ISSUANCE
who contracts mrsuch Projema with a contractors)licensed pursuant to the Contractor's
License law. ALTER (EA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
#I[ SANITARY YN
Owner Date DRAINS-FlAOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherebyaffrm thmlheve acenifiwtc of consents.self-i...ba. fecenificamof FIXTURES-PCR TRAP RECEIPT#
Workers C.mpensam.I...more ora certified copy tbereof(Sec.JIM,Lab C.)which PARK FEE Y N
Policy dl employee's undenhis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Comp a BUILDING DIVISION FEES
Company GAS-EASYSTEM-OVER 4(EA)Certified copy is hereby fumishcd. . ) PLANCIJECK FEE
Iff Certified copy is fled with the city inspeetion division. GREASIEWNDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Jose permit is(crone hundred dollaa(SI(K) SEWER-SANITARY-STORM EA.2WF1'. ENERGY HEar leas.)
I«reify that inthe perfomwce of Ne work for which Nis pcnnit isissued,lshell WAIERHFATERW/VENT/ELECTR
not employ any person in soy matter so as to became subject to the Workers PAID
z Compereaion Laws of Celifomia. Date WA TER SYSTEMOREATNG Dec Rettiptp
Applicant
z O NOTICE TO APPLICANT.If,after making this Celli ficatc of Exemption,you shouldURRMIPLMB. SQ.PT. TOTAL:^ become subject io Ne Worker's Compcnwfon provisions of the Labor Code,you mustfonhwith comply with such provisions m this panni,shall he dean A invoked. BUILDING FEF,CONSTRUCT ION LENDING AGENCY SEISMIC FEE Z Ihereby affimr Nat there is a c.nsWdion lending agency for the performance of
the work for which this pemut is issaed(Sec.3097.Civ.C.) TOTAL: IiI ECIRIC FEE S�0Lenders Name
O VLenders Address CAL P[RMI'1' FEE PLUMBING FEE1 certify that 1 have mad this application and stale that Ne above information is
cancer, I agree m comply with all city and county ordinances and Stam laws relating m MECHANICALFF,F. �,�
_ h
building construction,and hereby auNouu xprexntauves ofthiscity memerupen the
V Z abase-mentioned progeny for inspection purryrses. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmems,custa somexpemes which may many way accrue against said City AIR HANDLING UNIT CFO 10.000 CFM) US Soo
inconsequence of the grant ng of Nis permit.
AIR HANDLING UNIT(OVER 10,000 CFhU
--tans mor Apphessail narcmr Date EXHAUST FOOD(W/DUCT)
PAID
HAZARDOUSMATFTt1AL5DISCLOSURE HEATING UNIT(TO IW.(NIU BTU) Date ie- Ttp
Will the tipthe Cupend rtino
Mu buildingoccupanterreor handle Health and
C definedio the Cupertino Municipal Crile,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BT TOTAL:
Cede,Section Yes x)?wwrr''''
C1 Yes Jossvo VENTILATION PAN GLE Wort
REMD)
ABOILER-CHPOR100,00o ISSUANCE DATE
,IimlWill hcappliewtorfuturebuildingascupmtuxe uipmenmrdevittswhichemousair con sh inans,as defined by the Bay Arm Air Quality Managemen 'R I 000 )Distict ❑Yce XNo 5 FT. SEP 3 0 1994
1 have read the hatearma,materials osairememn under Chapter 6.95 of NCelifmnia Health&Safety Code,Sections 25505,25533rand 25536. I uadeymnd thaifthe building does nm currently have a tenant.Nat it is my responsibility to notify thGt1 r vr- k karcn uroV
aspam of the rtt -remenu which mast be met prior u)issuance of a Certificate o
eapeney �_�
5/3o/FH
Owner Or amhonaed agent Dae
TOTAL: ISSUED BY:NL kin:Tk my k,
OF CE