26914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOILO .ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. n C (�� A
BUILDING PROJEC'1'IDEN'1'IF'ICA'1'ION L o J 4
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
A06210 ZVOSS, I,/ (IAr CIT UNIT# LOT# ( u►
W S NAM PHO CONTRA R•S NAME: LIC NO:�� CO.C/
171 i / k.,CQ' N/C CONTROL.M
uppi:J11'11CI'/ENGI 'ER: LIC NO: A Ri: ❑
CONTACT: PHONE: BUILDING PERMIT INFG
QTY, ELECTRIC PERMIT' FEE
BLDG ELECT PL U MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz I hereby affimtthat l sralicensed under provisiotuofC'haprer9(Commencing with JOB DFSC ON
¢00 Section7UW)of Division 3 ofthe Business and Profeuions Core,and my limn.is in PANELS
FFy�1-. full forte and cfjj{{r.r�
FZW License ClassI.ic.X UPT0200 AMPS
vsQd Date Comore 201.1000 AMPS
20y?, SDECLA$ ION OVER 1000 AMPS SQ.IT.FLOOR AREA 5/SQ.Frf.
1 unde t ed as 1� md.•
r SIGNS ELECTRICAL
< Lice Prof
NER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.x04 I by of m I em exempt from the Contractors License Law for the
uviol'-vFi fnllo ng rcu C.Imn 7031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLF.INST.
f-Pa 0 Q which requires u permit to consumer,alter,improve,demolish,or repair any structure
to its issuance,also the applicant far such Permit file a sinedsuitentenT POWER DEVICES
prior requires pp pemli g
X p Ohm he is licensed pursuant b the)Of DLitune of the Contractors License Frov Law(Chapter
aXm�' 9(commcncing with Section 7000)afDivision7afthe Business end Profusions Code) SWIMMING POOL ELECTRIC VALUATION
Way or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
�ZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
G
not moorhen five hundred dollars(SSW). NEW RESIDENTIALELEC11 -SQ.
❑ work,
undepropemmisnemtendedwithwegesavthe(Ses.7W,Business Q STORIES TYPE CONSIR O
will doth.work,ands: he COeisnos i.License
I..ercd f, of
70 C4,Business
rntl Professions Code:The Contreaory Limine Lew dins nsn apply to an owner of
property whnboilds orimproves thereon,and whodmssuch work himselforthroughhie OCC. ROUP RES.UNITS
own employees,providecithat suchimprovementsam not intendedorofferedforaale.If,
however,the building or improvement is sold within one year ofcompletion,the owner- TOTAL:
huilder will have the burden of proving low he did not build ser improve for pmOmee of
le.).
❑ I,usowneroOhe property,am exclusively contracting with licensed contracture to QTY. PLUMBING PERMIT FEE 1+LGGD ZONE APN
construct the project(Sec.704,Business and Professions Co II The Contractors
License Lawdoesmt apply torn ownerofpropcny who builds or improves thereon,end PERMIT ISSUANCE
who contracts forsuch projects with a conrractons)licensed purg arm to the Contactors
[.I. I... ALTER-DRA �IN T-WATERHIA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far dtis reason BACK R PROTECT.DEVIC 17AZuTI FS
ANITARY V N_
Owner DateDRAINS PL . RECEIPT p
l
WORKMAN COMPENSATION DECLARATION RD. HOOT.TAX YN_
Cl Ihertby affirm Nati M1aveecenificete of consent to.INinsure.macenificme of FIXNR -PRECEIPT*Woke%Compensation mption insurance ma certified copy the...f(SO..3800,Lab C.)which aV Py KFL'E Y-N-
Car
o11Cmpin th' r OAS-P .SYSTE -1 NC.40l1TL S RECEIPT#
Policy N BUILDING DIVISION FEES
Company � GAS-HA SYSTEM-OV (fA) FLANCHHCKFCR
❑ CcsllleJ copy Is t eby OrtfianetL
,Cenilied copy is filed with the city inspection division. OREASPJI DUSTRLW INTERCEITO GRADING FEE.
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TR P SOILS FEE
COMPENSATION INSURANCE.
(This section nadoor becompletal iftlepermit is fortune handreddoll.rs(SIM) SEWER-SA TARY-STORM .2WIT. ENERGY FEE
or leas.)
I certify that in the perfmmane<of Ne work for which this permit is issued.)shall WATER HEA WN /ELEC R
nor employ any person in any manner so as to become subject to the WMkCm* PAID
Compen.rimi Lawsof California. Dare WATER SYSTEMIDBATING Date Receipt#
O Z Applicant
0 NOTICE TO APPLICANT:If,after making this Ceniftcute of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
fA become subject o the Worker's Compensation provisions of the labor Code,you must
a '�^ fntocith comply with such Provisions or this pctmit.holl be deemedmvoked. BUILDING PER
W Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
zI hereby affirm that them is a construction lending agency for the performance of
0 the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: 1JI @i ELECTRIC REE
t..i Lenders Name PLUMBING HE
F Lenders Address QTY. MECHANICAL PERMIT FEE
ULST 1 certify that I have read this application and suite that the above information is MECHANICAL FEE74 47
MU entree[.I agree to comply with all city and County ordinances andrame laws relating o PERMITISSUANCE
L) z buildingeomnuction,and Mmbyauthoriu nuruv..f Nis cirytoemerupon Ne CONSTRUCTION TAX
abovementioneA pro�C.poaesx
L17
. ALTER OR ADD TO MECH.
(We)agree ro amslesa the City of Cupertino against
liuhilitiu.juday in any wayucerve egeirursai 'ry AIR HANDLING UNIT ITO 10,1#0 CPM)
in coa.qu
AIR HANDLING UNIT(OVER 10,000 CFM)
nm c anUCunvucmr p EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOS HEATING UNIT(TO IW,000 BI'U) Ilse Receipt#
W e applicant or future building occupant store or handle hazmdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Safety HEATING UNIT(OVER IOq000 BTU) TOTAL:
Code,Section 25532(.)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
Will theapplicanturfutumbuildingoccupant usecquipmentordevices whichentit BOILER-COMP(3HP OR IOQ000 BTU) IIP' (1yC0
pranrdom air cunuiminama as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU))
umn? JAN 271995
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.PI'.
1 have read the hazardous materials rcgoirentcnts under,Chapter 6.95 of the I
Culifomiu lkalth&Safety Code,Seetiona 253x5.25533 and 25534.1underatandthaT V Uf Ir,i
if the huilAing Ame not curtemly have u
I.Ohm it is my responsibility ro notify the 1'1
cupmn of the requirements which must be mm prior to issuance of a Cenifleme of
Occupancy.
Owner or amhoriud Cacti Dam TOTAL: ISSUED BV:
OFFICE