26079 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO eat'.1INC-F7.ECTRTCA. PERMIT NO.
'APPLICATION/PERMIT PLUMBING-MECHANICAL 26079
BUILDING DIVISION BUILDING PROJECT[FIRST IFICA1]ON
BUILDINGA DRESS: /� SANITARY NO. TF.V �� LD 'T# LOT# �,APPLICAIIONSUBMITIALDA
-1
OWNERNAME: PHONE: COM-' ACTOR'SNAME: f LIC NO: NIC •CONTROL,#
5-7 f 593�P
- ARCH]'TECUENGINP.ER: ^ LIC NO: ADDRESS,
//O(J of ❑
CONTACT: m PHONE:(/Q�) BUILDING PERMIT INFO
7 ) QTY. ELECTRIC PERMIT FEE
6 q DG_ ELECT PLUMB MliCll
O _ PERMIT ISSUANCE }LJ�/I/`�' El El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
o04Z I herebyaffmrnthn l son licensed under provismaso1'Cnapmr9(commeneing with
WOO Section 7000)of Division 3 sprite Busio.o.rlProfessions Code.and my license is in PANELS
[-WF. full force mW cf
QyW Liccmc Class Lic.# C�1 IIP TO 200 AMPS
y<a m Conti«tor 201-1000 AMPS
rO�Z p I ARC]III'HCpS DECLARATION OVER Iqp AMPS SQ,IT.FLOOR AREA $/SQ.FT.
O L— 1 umlerstand my plans aball be used as public records.
y W SIGNS ELECTRICAL
Licensed professional
m< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
XOe.U I hereby affirm that 1 an exempt from the Contractor's License Law for the
W 3 W vFi
following reason.(Section 9031.5.Business and Professions Code:Any city or county TEMR METER OR POLE INST.
t:Eto which requires apennir to construct,alter,improve,demolish,.,repair anystructum
��Y� pnoo its issuance,also mm Ne applicant forsuch permiuo file a signedsusterrent POWER DEVICES
rt
ee y.Q that he is licensed pursuant to the provisions of the Contractors License Law(CTapter aVALUATION Re 9(mm
maveing with Such. of Division 3 of the Business said Professions Cade) SWIMMING POOL ELECTRIC
or that he is exempt therefmmand the basis for the ollegMexemptim.Anyvislatiosf 1 ^
tZa Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES 1
t more Ihnn Five hundred dollars(55(10). NEW RESIDENTIAL ELECT11 _SQ.FT.
x n❑ 1,nsownensf lhepmperty,nrmyemploy«switM1 wegc....heirsolecempematim. STORIES TYPT;CONSTRUCf]ON
i3= will dome work.and the structure isms imendmor offered fm safe(See.9044,Business
and Professions Calc:The Conuacuors License Law does not apply to an owner of
pmpony whomi]ds orimproves thereon and who does such work himselforthrougnhis OCC GROUP RFS.UNITS
mployees.lnm ided that such improvements are not intended m offared for mde.If,
how
the building or improvement is sold within one yearofeamFletion.lie owner- TOTAL:
builder will have the burden of proving Into he did tot build in improve for purpose of
tole.). QTY. PLUMBING PERMIT FEF: ILOODZONE APN
❑ I.mownerottheprolwny.amexclusivelycontmetingwithlicensedc.m.at.,a
,minuet the project(Sec.7044.Business and professions Code:)The Conu¢mr's
I!icenm Lound«snot apply toanownerofpropcny whobuildserimprovu R¢rmn,end PERMIT ISSUANCE
who couacteforsucb projects with.....Omy)licensed pursuanuo Ne Contac, x ALTER-DRAIN&VENT- �T 6T) FLE SUMMARY
Li«naeLao. 3
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.D 11TSIDE F F.S
R Y N
Owner Dam RFCEIFr#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARE S 00L.TAX YN
❑ Iherchyaffirmthut l have a cmificateofcommrno self-insure,or a cefificare of FIXTURES-PER TRA RECEIPT#
Worketa'Campcnantio Insurance ma cenifmed copy thcomf(See.3900.Lab C.)which PARK FEE Y N
covers ell employee's under this permit. GAS-PA.SYSTEM-I INC.4 OUTLETS RDIVIST#
Policy# BUILDINGDIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCEIECK FER
Cenifed copy is henchy fumished.
Certified copy is filed with the city inspection division. GREASWINDUs'TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not In completed ifthe permit is person hundred dollax($10)) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orless.)
I cenify thatln the parr'orronce,df the work for whiehthis pcm,nonacid,Ishell WATER HEATER W/VENT/F,LECTR
nut employ any person in any manner. as m became mbjcm to the Workers' PAID
Compensation Lawsof California. Date to WATER SYSTEM(IREATING Dam Receipt#
OZ Applicant
,Z 2 NOTICE TO APPLICANT:if,thfie,making this Certificate of Exemption,you should NEW RESIDENTIAL.PI-MIL SQ.FT. T L
T/J became subj«t to the Wnrkeex Campcneauo provisions of the Labor Code.You must
forthwith comply with such provisions or this permit shall he deemed mvoked. BUILDING HE
r� CONSTRUCTION LENDING AGENCY SEISMIC IEE
U
z
1 herem N
by affirm osn
hen is a cuction lending agency for the performance of
U O me work for which roPermit peis loaned(see.309 ,ci..e.) TOTAL.: ELECTRICHM
Lenders Name TY. MECIIANICAL PERMIT FEE PLUMBING FEE
0 F' Lender's Address Q
V I cenify that I have read this application and suite that the above information is MECHANICAL FEE
eimect.logrec to comply with all city and county oMivnttsend sate laws relating to PERMIT ISSUANCE'
F-' building comeneion,and hereby authonim mpmsentativesofthiscity to enter upon the CONSTRUMIONTAX
U Z "hove-memcd ionpr.,ny far inspection purposes. ALTER OR ADD TO MECH.(We)agree m save,indemnify and k«p harmless the City of Cupertino against
liabilities,judgmems,costs and expenses which may in any way accrueagaina mid City AIR HANDLING UNIT(TO 10.000 CFM)
comic
� pb
oma ynmce ufthegmn !!U hng of3/a/9y
AIR HANDLING UNIT(OVER 10,000 CFM)
-t'�A b EXHAUST HOOD
Sigmmre of Appficam/Cummcmr Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building wampant store or handle hwmJous material
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the l lealth and Safety HEATING ON]'1'(OVER 100,000 BTU)
Code.Section 25532(.)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the appli=tor future buildinguccupmt usecquipment ordeviceswhichemit BOILER-COMP LIFE OR 100,000 BT U)
hvsrdous air amtarmaim,as defined by the Bay Amo Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? P A P P
ms ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. NAR
I have read the ar�ouh'medals reyuiremems under Chapter 6,95 of the "�.\ -
CalifomisHealth&Safety CwJ,Sections 25505,25533 and 25534. 1 understandAR that 1nM
ifthe building does nam currently have a tenant.that it is my responsibility to notify the . 1994
occupant of the requirement which must de mem prior I issuoce of a Ccrtificmc of
Occupancy.
Ownenmr awmr, em Date TOTAL: ISSUED BY:
OFFICE
1 '