26760 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILIJI i-F.LRC'rRICAL PERMITNO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION t BUILDING PROJECTIDENTIFICATION
BUILDIIINPG``AyyDAADIlRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
i�'v� • lU UNIT# t LOTH
O NIiRSN N Aa�s/� �Py�plFg) CONII RA OR'5 AM LIC NO: N/C CONTROL
•A CHITECT/F1111,F.F.R: L`J LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. -ELECMIC PERMIT FEE BUILDING PP.RMIT INFU
A` k fB.OG ELECT PLUMB E U
s� PERMITISSUANCH / L{raJ IY�/l�� •Jp�/`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
paz I hereby affirm that Into licensed underpmectomcfChapter0(commencing with ,
6100Section 9000)of Divisind 3oftha Businossand Professions Code,and my license is In PANELS
MbE full force and effect.
dz pl License Class Llc.p UP 90200 AMPS aL' rIp,
y a y Data C capanar 201-I"AMPS
FO m'
—ARCHITECTS DECLARATION SQ.FT.FLOOR AREA .FT.
ZOIn'� OVER IOfIt1AMP5
O2^O 1 understand my pions shall be used as public records. CL4
F^ ; - SIGNS ELECTRICAL /J.
<d Licensed Professional `��
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
r,J
in(,OyU I hereby if,.that I an exempt from the Comrecoma License Law fur the
61'36cp fallowing reason(Section 7031.5,Businessind Professions Code:Any eir,mammy TEMP.METERORPOLEINST. '
which requires a Permit o construct,Nraq improve,demolish,or repair any structure
NS Y2 poor to its issuance,also requires the applicant for such permit to file a signed s[a¢mem POWERDEVICES
uJ d0 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a SWIMMING POOL.ELECTRIC
a e 9 law
a wisexempt Section](g0)of basis
(he
the Business and Professions Code) - VALIUATI/O�N
�ZQ onhat 7031.5 by spy
applicant
the basisfnrbe tsthed exemption.Any violation of OUTLETS-SWITCHES-FIXTURES CO ��
g..yY Section LS by any applicant forapemlit subjects the applicemmaoivil pena¢y of U V
yap G norm rot ban five hundred dollars($500). NEW RE9IDP.NTIAC BLECTR_SQ.FT.
1,nsownerafrbeproperty,ormyemployeeswithwapsastheirsolecompensation, STORIES TYPECONSTRUCPION
pW, will thewons andd: sou Comm License Low
apply to an Business
and Property
wh ons Code:The Co therso's Incense Law does not apply to an owner of
properly whobuilds or improves thereon,and whodoes such workhimeNfor[hroughhis - -
employees,provided thu[suchimprovemenre menmin[ended orofferedforsale.If, OCC.GROUP RES.UNITS
however,the huile ingor improvement is sold Williams,yearofcompletion,the owner- -
builder will have the burden of proving that he diyn\ot build or improve for purpose of
sale.).
❑ I,asnwaernfthepmpeny,andexclusively
CC. co ngwithlicensed contranors to QTY' PLUMBING PERMIT FEE FLOOD ZONE. APN
Iutruct the project(S ]044,Business end fie ons Cade)no Contractors - - -
LicenseLawdoesnotapplytoanownerotpr uildso vesthereon,and PERMIT ISSUANCE,
whocnnaamsfineachpmjecte withaconrraC r(s li nsed um the Contractors ALTER DRAIN@VGNT-WATER(FA)
License Law. FEE SUMMARY
OUTSI❑ I am exempt under Sec. P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y DC�� N
Owner - ate - -
RECEIPT If
COND
AREA
ROOF.. , .
WORKMAN COMPEN A N TION DRAINS-FLOORSCHOOL TAX Y
❑ Herneedf Ccyafflrm thatlhavee cirII a mdc. h f-insure,oracertificate of FIXTURES- RECF.IPf#
• mkers'Campensution lmurance or n mdc ythxof(Sm.3g00.Lab C.J which PF,R TRAP PARK HE Y N
covers all employees under the amtiL GA9-fiA.SYSTEM)INC.40I1TLHTS ECEI #
Policy# BUIL C IVT ON FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PIANCHECK FEE>1_!
❑ Certified copy is hereby mused.
❑ Cenified copy is tiled with the city insp ion Division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING rhii
1.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOTLS F E ^Its
COMPENSATION INSURANCE
(Thissection neetl not be completedifihepermitisfor onehundred dollnre($100) SEWER-SANITARY-STORM EA,200F , ENERGY PEE
mous.)
I _
readily that in the perfnnnanceof the work for which this perm is issued,l shall WATER HEATER W/VENT'/ELECTR -
not employ any person in any manner so as to become subject to the Warkere' PAID
Compensation Lawsof Califomie. Duro WATER SYSTEM/TREATING pate Receipt#
Q z Applicant - -
Iry� C NOTICE TO APPLICANT:if.after making[his Certificate of Exemption,you should NEW RESIDENTIAL FLOE. SQ,FT. _ TOTAL:
r VJ become subject to the Workers Compehspond provisions of the Labor Cade,you must
moi . fordvith comply with such provisians or this permit shall be deemed revokul. BUILDING FEE
W a CONSTRUCTION LENDING AGENCY � Ii . SEISMIC FEE I O
7-. 1 hereby affirm that there is a construction lending agency for the performance of i ELECTRIC F
V O the work for which this permit is issued(Sea 309],Civ.CJ
LLI I—I Lenders Name
Leaders AdPLUMBI +Edress - QTY. MECHANICAL PERMIT FEE "
L) 1 certify that 1 have read this application and stem that the above informmi.a is
Fa correct.Iagree a,comply with all city and county ordinances and state laws mating1. PERMITISSUANCE > MECHfiqXSA.FEE
building construction,and hereby authorize representatives of this city to Interment the - - CONSTR TONT
V z akwe-memioned property for inspection purposes. ALT ER OR ADD TO MECH. YR
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses whichmay in my way accrue mistsaid 'y AIR HANDLING UNIT(TO 10,0110 CFM)
in�nseyuen the gmntin this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
gnatureo pP team/Cortmetor - De EXHAUS' HOOD(W/DUCT)' PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0051 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
os defined by the Coppola.Municipal Civil,Chapter 9,12,and the Health odd Safety HEATING UNIT(OVER 100,000 BTU) T L:
a Code.Section 25532(a)9 I
❑Yes ❑No VENTILATION FAN(SINGLE REST[))
BOILER-COMP(IUP OR 108000 BTU) ISSUANCE DATE
Will air comommns a building by
asacipanBayat AreaAen Qualior ty
Manas agemech nt /91 D
hazardous air conmminams as defined by the Bey Area Air Qualify Management BOILER-COMP OVER 100,000 BTU - Y-'
District? t, ( ) -
❑Yes ❑No 'NEW RESIDENTIAL MECH.—SQ.FT. q
LL AUG 1994
1 have rend the hazardous matioals requirements under Chapter 695 of the ^�
if the building
ing does
&Safety ur Code,Sabana 25505,25333 and sponse I ityunderstand
otif that
occueradidgdaesnotcurmndyhave atenam,et protein
myresponsibility Certificate
the - V
occupam of the regoiremems which must M mer prior m issuance of a Certifcate of � �1"4UK(;h/11w�f
Occupancy. it - I M
Owner or authorized agent - Date T ISSUED BY:�
OFFIC