26344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOLD1 .- ,h. RI AL PERMrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C O A
BUILDING DIVISION IIIIII.DING PROJEC'TIDENTIFICATION U J L�
BUILDING ADDRESS: SANITARY NO. APPLICAT/IOONSUUB�MITTALAT
DE
L/
W1r�s vvzt ` � PIQFI 1 UNIT# LOT# ��{w
OW SN
Q NIC CONTROL#
•ARCHITE NNGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INPO
QTY. ELECTRIC PERMIT FEE,
CLECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
pd.Z Ihereby affirm that lam licensed underprovisionsof Chapter9(commencing with TOB DESCRIPTION
11100 Section 7")of Division 3 ofthe Business and Professions Cale,and my license is in PANELS �7
full force and effect.
cw,
F Z License Class UPT02MAMPS Lin,# g/� t
m❑rn Dale Contractor 201 1000 AMPS S FT.FLOOR AREA 5/SQ.PT.
ZOryQ
ii2 ARCHITECTS DECLARATION OVER HIM AMPS
O1 underam.d my plans shall busere
e d as public coNs.
z SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDERDECLARATION Cmanum' SPECIAL CIRCUIT/MISC.
5;6
l' 1 hereby n.(Se thin I am exempt from the Comm�ors License Lew for the
which
renes.pa nit to crainn,tin ass and ere.dein h.a,reAny city m county TEMP.METER OR POLE INST.
I:E4 y 7 which require a permit re wnsmct,alter,improve,demolish,or...it any nmcturt
Kn<f primta lbissused aBoin to
throwiti nsof h such pemtors filLicense
La statement POWER DEVICES
W Q O that he is licensed puauanuo Ne provisions of the Contractors Licenu law(Chapter
a 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Mw .r thin he is exempt therefrom and the hasis for the alleged exemption.My violation of OUTLETS.SWITCHES FIXTURES
GSection 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of
not more than fivfffi hundred NEW RESIDFCfIALELECIR _SQ.FT. STORIES TYMCONSTRUCTION
❑ othe wnernfNeestrucy,e is not plodavlorNwagesavhei(reals compensation,
and Professions
and the he Contommim kende Law
os Irritate an owner
ss
of
and eryabrorm Cale:The,,.tendo ri License taw doe not apply lf an owner i.
propemploy s,providMirovuthimpmvmenis oesauch wdr oroffemf sale.I, OCC,GROUP RES.UNITS
c)wn employees,providedthatauehimprovld wit in neyearofmandeded theown If,
however,the have
tburden of ementMoving.that
he idnoneyem or improve
for
thrower- TOTAL:
hie.). will bout the burden of proving that he Aid not build or improve for puHaaee of
e).
❑ Lasownerof the properly,emudusively conhacting with littmedconoedorsm QTY. PLUMBING PERMT FEE FLOOD ZONE pPN
construct the pmjmt(Sec.701 Business and Professions Code:)The Commences PERMIT ISSUANCE
License law does not apply loan owner of popearty w ho m it ds or improves thereon,ertd
whocoatmcts forsuch projectswitb a communists)licensed pursuant ncthe Contrecncrs
License Law. ALTER-DRAIN&VENT-WATER(EA) FCC SUMMARY
❑ 1 stn exempt under Sec. ,B as P C for this reason BACK FLOW PROTECT.D17VICE OUI TI-DE-MM
SANITARY V N
Owner Data - RECEIPT as
DRAINS-MOOR,BOOP,AREA,COND.
WORKMANCOMPENSATIONDECLARA.... SCHOOL TAX Y N
❑ err reC. sffiamthatlhmveattnifuteof consemncrof(Ses.380.as C.) RECEIPI'p
Workers Compenaotionlmumnremacenifed copy thcreof(SaJ800,Lab C.)which PARK FEE YN
covers all employee's under this Permit. LC SYS M-I INC.4 OUTLETS RECEIPT It
Policy N . . BUILDING DIVISION FEES
Company ) Mp n PLANCHECK FEE.
❑ Cenifiedcopyisherebyfamiehed. 11 PEI
❑' Certified copy is filed with the city inspection division. r N C GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' see g
eo
COMPENSATION INSURANCE 1k
(Thissection..do.t becompldMif the permit ie for one handrcd dollen S #•..200FT. �GNf:R
or le¢.J
(certify that in the performance of the work for which this permit is issue A Nl'/ELECTS �' I
not employ any person in any m u 0 become subject to the PAID [ u
z Compensation Tawsof California. Date so Dir 11,5 B
O O Applicant SW
NOTICE TO APPLICANT:IL after making this Cenlfcate of Exemption,y P SQ.PT.
r become subject to the Workers Compensation provisions of the Labor Code,yo
Chi forthwith comply w th such provisions or this permit shall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY ._s S171SMIC FEE
^a I hereby.fill...Thor he.is a conswctim lending agency for the performance of ELECTRIC FEE
U O the work for which this Print is issued(Sec.3097,Civ.C.)
Lenders Name �V•
PTinders Address • )TE PLUMBING FEE
V T terrify that I have reed this eppliation and sum that the above brimmed.is
7s a correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICALME
�^ Ln ball gamm,.c' ,and herebytollmdre represenutivesufthis city to enterupan the CONSTRUCDON TAX
L) above-mentio p ny fm inspection purposes. ALT17R OR ADD TO MECII.
(We) see nc. ere,indemnify and keep harmless Ne City of Catania.against
liabiliti udgmc c s endexpenseswhichttuy in any way ettmeegalnst said City AIR HANDLING UNIT(TO 16,oW CFM)
ante un p(this Permit.
` AIR HANDLING UNIT(OVER 10."CFM)
igratio plicantl munator J ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant m future building occupant nom or handle haeardous material
as defined by the Cupertino Municipal Code,Ch.ptm 9.12,and the Health and Safety HEATING UNIT(OVER 100,00 BTU) TOTAL:
Cade,Section 23512(e)?
❑Yee ❑No VENTILATION PAN(SINGLE RESID)
Will the apPlicunt orluwre M1uildingoccupem useequipmem nrdevicee which noir BOILER-COMP(3HPOR IW,g))BTU)
SOANCIMATE
hosardous air contammunts as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) MAY 0 5
District? ,1994
❑Ya El No NEW RESIDENTIAL MECH.-SQ.PT.
1 have read the htimmus materials rcquircmen0 under Chapter 6.95 of the CITY Uf Garti uvU
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand h that h 111v,u
if the building does not currently have a tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prior to issuance of a Cenificate of
I
Occupancy.
r
,
Ownerm authorized agent Date TOTAL: ISSUED BY
QFICE
S