26723APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO '- -
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IO MECHANICAL
- � BUILDING PROJEC]'IOENTIPIWTIUY
PBRMIrNo.
26723
BUILDING ADDRESS://,,��
SANITARY NO.
APPLICATIONSUBMITTALDATE
% G(/ UNIT# LOTH
OW b ME: PHONE:
CONTRACT'OR'S NAME: LIC NO:\\\
N/C
CONTHOI.N
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J0 III L6
J ❑
1ARCHI /F.N (NEER: LIC NO:
P
A DRS .
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CONTACT: PHONE: Yq q
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QTY. EJ.eCPRIC PERMIT,, FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
W/ ; �` y�p
-
PERMITISSUANCE
M
❑ E
LICENSED CONTRACTOR'S DECLARATION
1 herebyaffirrn Jut lam licensed under proviaiorsofCTufner9 (commencing whin
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
UPT0200AMPS
Section 7000) of Division 3 of the Business and Profession Code, grad my license is in
full forceond+Bpc� t'n
License Clns ` ` Lo. p
V
201 - 11100 AMPS
Dme Contractor
ARCHITECT'S DECLARATION
I understand my plans shell be used as public records.
OVER ]ODD AMPS
SQ. Ff. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby .(firm shat 1 am g,xemla from the Contractor's Ucetue law fm the
following season. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to construct. aper, improve, demolish, or sepuw any stmcmre
prior to its issuance, also requires the applicant for such pcnnitm file a signed statement
SPECIAL CIRCUIT/MISC.
+\ \-
'
TEMP. METER OR POLE MST.
POWER DEVICES
thug he is licensed pursuant to the Provisions of the Contractor's License Law (Chapter1
9(commencing with Section 7") of Division 3 of the Business and Profusions Cade
SWIMMING POOL ELECTRIC) ., `.e
VALUATION
or thus he isexempt thereframandthe basis falling, alleged exemption. Any violation of
Permit subjects the applicana civil penalty of
Section 7031.5 by any applicant for n t
OUTLETS•SWITCHESFIXTURES ff
-
V
NEW RESIDENTIAL ELECIR SQ.
Q
not more than five hundred dollars (8500).
❑ Lnanwnernfthepropery, ormyernployecswithwegee astheirsolecompcnsation,
STOR LS
TYPE CONSTRUCTION
will darhe work, and the ahumurc a Bnirrcsf
and Pndevions Code: The Contractors License Lew ams not apply m m owner of
eact.e Lie se Law taxes nor
pmpertywhobuillomimprovenhermn.and whodmssuch workhiroselforthrough his
ownemployere,providedtheuuch improvememssremnintmdedoroffered forsele. It,
OCC. GROUP
RES. UNITS
TOTAL:
however, the buildingorimprovement issold within one yearofcompletion, the owner.
builder will have the burden of proving that he did stat build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ 1,usowncrofthepmpery,amexclusivelycantr fingwithlicensedcon=tonto
PLO DZC3NE
APN
construct the project (Sec. 7044, Business and Professional Code:) The Contractor's
License Law does not apply loan owmerofpropery who buildsorimpovea thereon,and
PERMIT ISSUANCE
who contracts forsuch projects with a contracmr(s) licensed pumard tothe Columbus
Licene Law.
ALTER
_ PEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this season
BACK FLOW PROTECT. DEVICE
DERIDE
SANITARY —N—
RECEIPT#
Owner - Dem
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
FIXTURES - PER TRAP
❑ Iherebyaff that i have a certificate ofconent cosalf-insure. or a certificate of
Workers'Compmeamim hadmnce or a certified copy thereof(Sec. 3800, lab C.) which
Policy eHam,[. cjtr this ppmi t
Policy N_Y7QQ 'Zfl �'�Dy
RECEIPT'#
PARK FEE Y N_
RECMPT p
GAS - PA. SYSIBM-I INC, 4 OUTLETS
BUILDING DIVISION FEES
company —T -l -t- — ,; g, slid. 4
❑ Cerifed copy is hereby furnished.
1W Certified copy is filed wish the city inspection division.
GAS- CA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
GREASPJINDUSTRL WASTE INTERCEPTOR
GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASCTRAP
SOILS FEE
COMPENSATION INSURANCE'
SEWER - SANITARY - STORM EA. 200FT.
ENERGYFELr
(Thiaeectionneed nos becompletedHthe permit is fwone hundreddoll®(SIM)
or lay.)
WATER I IIATER W/VBM'/ELF.CIR
I calmly that in the perfomtarrce of the work for which this permil is issued. 109,
not employ any person in any manner so as to became subject m the Workers'
PAID
ComPenwtion Lawsof Califomia. Date
WATER SYSTEMI REATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDE.M'IAL PLMB. SQ. FL
TOTAL:
become subject to the Workers Compensation provision of the labor Code, you must
forthwith comply with such provisions or this permit shall be ducted revoked.
BUILDING TEF,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency fm the performance of
the work for which this pemtit is issued (Sm 3097, Civ. C.)
TOTAL:
ELECTRIC HE
Landels Name
LcndcraAddress
I verify that I have read this application and etam that the above information t
rem. Ingres ro comply wish all ciryarM chanty ordrvnces end nam laws mleungm
., .. : ` • -
QTY -`: ] MECIiANICAL PERMIT }'".'FEE,,
PLUMBING FEE
1 PERMIT ISSUANCE dQ
MECHANICAL FEE
o-QD
building construction. andhereby agthoriu representative ofthiscity m enter upon the
ab
above-mentioned properly for inspection purposes.
J
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree in save, indemnify and keep handless the City of Cupertino against
Tubi lities,judgmens, casts and expenses which may inenlsv� accrue s st said City
AIR HANDLING UNIT (1010.000 CFM)
in consequence e r INis pew It. _
AIR HANDLING UNIT (OVER 10,000 CFM)
.ignamreofAPPlicent/Conwy
EXHAUST HOODW/DUC
PAID
HEATING UNIT(TD I00,000 BTU) (70
Dote Rmso,.N
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or for= building oceupmt store or handle harardmas material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and she Health and Safety
HEATING UND'(OVLR 100,000 ETU)
TOTAL:
160-000
VENTILATION PAN (SINGLE REBID)
Codes Section 25532(a)?
❑ you ❑ No
BOILER- COMP GHP OR 100,000BTU)
ISSUANCE DATE
AlTT
pi E g.f
Will thea Iicamon6soe buildinencu
pp g punt uscequipmentordevitte which emit
humolms air contaminants ns defined by the Bay Area Air Quality Management
District?
BOILER -COMP (OVER IOO,WB BTU)
Cl Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
I have read the hamstrings materials requirements under Chapter 6.95 of the
NOV 15 1994
California Health & Safety Code, Sections 25505, M533 and 25534. I mWcntand that
'
if the building does not currently have a among. that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
f
C11"r ur laws CIn 111 ili
Occupancy.
ISSUED BY:
Owner or au la ri.d agent Dom
I OTAL: -0
OFFICE