26566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x H.DIhr-ELECTRI AL PERMiTNO.
PLUMBING MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BI111DING PROJCCIDNN TIFICAIION 26566
BUILDING ADDRFS9 SANITARY NO. APPLICATIONSUBMRTALDATE
��2 - 1169sai 'r�JUNIT0 LOT'#
OW BRSNAMP N& I_ -/n CO TR OR NAME) LICNO:
Vs•G3/! V/11'.\ N/C CONTROL#
�ARCHI' IT—C'/ENGINEER: LIC NO: ADORNS S_z *656MLJCONTACT: PHONE: QTY. � HLECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT PLUUMMB""" MECH
PERMIT ISSUANCE 0 ❑ ly- El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL �-'k
pq.Z Iherebyaffirmtbalamlicensed underprovisionsofChapar9fcommencing with IOBD � J
{400 Section 7000)of Division 3 ofthe Business and Pretenders Code,and my license is in PANELS ttsr�rrsrVVVVV` (s
qr�4 arc Can`eft Lic.# Z�id UP TO 200 AMPS S\ "�--`�k�/1•�
m Dae I �Commnor 201-1000 AMPS
7.Oy ARCHITECTS DEC TTIO s SQ.PT.FLOOR ABPA S/SQ.FT.
O Z, I undentiod my phare skull bu used m pub r moral
c ds. OVER 1000 AMPS
SIGNS ELECTRICAL
d Licensed Profe shoal Y
rowu OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOau I hereby affirm that I um exempt from the Contractors License Law for the
Wes` VOq following reason,(Section 7031.5,Business unit Professions Code:Any city or county TEMP.MITER OR POLE INST.
iil ONa which requires it permit to construct,alcor,improve,demolish,or repair any tantrum
;!t>-� prions its issuance.ulwornhiircs the apposes for such permit to file a signed soccment POWER DEVICES
q0 that he is heretical pursuant o the provisions of tha Commnars Lima.Law(Chapter SWIMMING POOL ELECTRIC
gL0r 9(commencing with Section 7000)of Division 3of the Business and Rmde)ofessioCoVALUATION
ts-,y or that he is exampuheraframand the load,(a,theallegcJ exemption.Any violmmq.l
t Section 7031,5 by anyap,hemt for.pemtit subjects t haapplicant o.uitA pen.Ityof OITfLETS-SWITCHES-FIM USES
O rat more than five hundred donors($500). NEW RFSIUI:NTIAL ELIiC1R —SQ.
��m ❑ 1,mownem(thcpropcny,ormyemployaawithwngcs asthcirmle
compensation, F1'. Icompensation, STORIES TYPECONSTRUCON
T
3_ will Jothe work,anJ the atmcturt is not immruJedorofferul for mIe(Sm.7B44,Bmdneas
Rod Profcasinnx Code:The Contractors License Law does not apply to an owner of
propvtty whobuilds urimpowes themon.and who does such work himsclforthrough his OCC.GROUP RE'S.
ownemployees,providW Nat wchimprovaments nre notimended aro(fercd Tarsale.If.
however,the buildingor improvement is mid withinone yearefcomplinion,the owner- TOTAL:
builder will have the burden of proving that he did not build m improve for purpose of
sole).
❑ 1,vownerofthepropery,.m exclusivelymmonling with licensed Contrmmn to QTY. PLUMBING PERMIT FTC FLOOD%ONE APN
construct the project(Sm.7044,Business and Professions Code:)The Contractor's =
PERMIT ISSUANCE
License Law does not apply to an ownerof popery who builds or improves mamma.and
whocomructs for such projects with acomructor(s)licensed pursuanuothe Contmumr's
License ALTER (PA) FEE SUMMARY
.
❑ I aLawin exempt under Sec. ,B&P C for this reuom ACK FLOW ROTECf.DEVICG OUTSIDE ES
SANITARY YN
owner Date RECEIPT#
WORKMAN COMPENSATION UIiC1,ARATION -MOOR.ROOF,ARF.A,WND. SCHOOLTAX r YN_
❑ Thereby nllirm thalhuve acertiEcem of consem oself-insure,urn cenificme of
FIXTURES-PER TRAP RECEIPT#
Wnrkers'Compensatihnlmutanu orncenifiW wpy therrof(Sec.3gp0,Lab CJ which PARK I'EE YN
covers all employee's under this permit. GAS-FA.SYSTEM-I INC.4 OUTLETS RECEIPTp
Policy# BUILDING DIVISION FTIS
Co'nPany GAS'-EA.SYSTEM.OVER 4(EA) PLANCHECK FUH
❑ Certified copy is hereby famish vi.
❑ Coifed ropy is fled with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP. SOILS FEE
COMPENSATION INSURANCE
(Thissciionneadnothr,Completedifthepermit isforonehundreddollos($100) SEWER.SANT TARY-STORM PA.201 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ oa,Iaason in any manner art as o hecrme subject to the Workers' PAID
Z Comperimlima Lmmof Califamia. Data WATER SYSTEM/I'RFATING Date Neceipt#
Applicant
7� Q NOT ICE TO APPLICANT:If,after making this Certificate ofEsemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
a become subject to the Worker's Compensation provisions of the Labra Code,you must
forthwith comply with such provisions or this permit shall l he deemed revoked. BUILDING PER
Q7-. CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby notion that here is a construction lending agency for the parformance of
V the work for which mss permit is lssued(See.3097,Civ.C.) ELECTRIC FEE
Lender x Name
0 U Leaden Add.. QTY, MECHANICAL PERMIT HE PLUMBING PEE
I certify that I have mad this application and state that the above information is MECHANICAL FEE coral Iugrcevacompiy with all eiryand cnunry.Mi....as and state laws relating to PERMIT ISSUANCE.
building mmnaGion,and hereby aadmiriOn oTir semntivw hf this city toentarurym the CONSTRUCTION'1'AX
L) Z ulxwe-mentlonal property,for inspection purpnes. ALTER OR ADD TO MRCII.
(Wr)agree to save,imlemnify and keep harMen the City of Cupertino against
Iiabilitias,judgments,costs and expenses which may in any way sector,against mid City AIR HANDLING UNIT(TO IB."CFM)
Incn sego nee of f thio Permit.
5 AIR HANDLING UNIT(OVER 10,01X1 CFM)
a)—
,"gratil ApplicanuC nt emr Dole EXHAUST HOOD(WNUC17
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dore Receipt#
Will theapplicant mfuore building occupant some orbaodle hamrdous material HEATING UNIT(OVER 108,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cale.Chapter9.12,and the I lealth and Safety
Code,Section 25532(a)?
1-1 Yes, 1:1 Na VENTILATION FAN(SINGLE RFSID)
Will the applicanmrfumrtbuildingoccupam usccyuipmem ordevicee whichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
•
It do' air contaminants as defined by the Bay Area Au Quality Management BOILER-COMP(OVER 100,000 BTU) g DlnricsT % ID
❑Yet ❑No NEW RI?SIUENTIAf.MCCH. SQ.PI'.
I have mad the haz:Woua materials requirements order Chapter 6.95 of the JUN 151994
C.lifomia I le.hh&Safety Cade.S«tion.25505,25533 and 25534.1 understand that
it the M1nilding does nut curzenJy halvealonunt,Nat it ie my respnmihility to notify the ^
hceopam of the requhmarnae which must he mu prior to Issuance of a Cendficae of
Occupancy. Vf (aur
Owner or amhodned agent - Data TOTAL: ISSUED BY:
OFFICE