26272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIUILDIYf1-ELLCCA-17— PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26272
BUILDING DIVISION BUILDING PROJECT]DENT IFYCAI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATIi
e UNIT# LOT#
OWN[ MH 41 PHONE: CONTRAfiTOR'S NAME: LICNO: N/C CONTROL
'ON
• �0//� BUIL" r
RCIII GCT/IiNGINEIJU LIC NO: O ADDRESS:�Op'D yL-1� '(�'?JN 1frC4— El
TACP: A+ - " rw Yt peQTY. ELECTRIC PERMIT FEF
BLDG BUILDING PERMIT INFO
17
7 PERMIT ISSUANCE PLUMB
MECH
tAtr ` 565,41106
E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mwz I hereby offieudim l am licensed underprovisions ofCha1mr9(Imaramdng with
W,00 Sovlion]W0)of Division 3o[the Business and Professions Code,andmy llcerm is in PANELS
wZt— full force and effect. IzA
Fw [)am se Conn , .r9x UPT02W AMPS
to,may Dam Convector Ci"� 20L I000 AMPS
`
l Oyz RCHITLCPSDECLARATION OVER 1"AMPS SQ.IT.FLOOR AREA EISQ.Ff,
Oz—C Iugdenlund my phos,mll bemed a'public records. LZ
oz—aSIGNS ELECTRICAL 1ZZ� l �+
Py$ Licensed Professional
< tY OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. rl 1 JJ�V O
5E5�Oy V 1 hereby affirm clors that 1 am exempt from the CummLicense Law fur the
1_-
,y Lao, following reason.(Station 7031.5,Business and Professions Coda Any city minority TEMP.METER OR POLE INST.
C< which talvires a permit to emswa,alma improve,demolish,or rtpeir any strutters
$!�12 prior tons issoance,aEu requires the u"licarnforcuch permit to asignc4 statement POWER DEVICES
a a Ibnt he is licensed pursuant to the provisions ortha Contractor's License Law(Chapter
iX°� 9(commencing with Section VOW)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ty_y Secoh7031.5 by any efromand the ferrat subjects thedexemptt to civil Pinion of
F-ZY Section]031.5 by any apelicamfora permit subjects the applicannoacivil Penalty of OIIfLEI'S-SWITCHES-FlXTURFS t O 1 �•
�$
l i more than five hundred dollars(E51Np. k�a NEWRESIDENTIALELECB _SQ.FI'. STORIES/(� TYPE CONS'IRUCION
� � [J 1. sownerofthepropcny,ormyemploy«swish wages astheirsolecomceasation, \`
x322 will do the work.and the slmeture is not Mendedoroffered for sele(See.701 Business
and Professions Code:The Contractor's License Law does not apply to an owner of `t -•
property who builds orimproves thereon,and who does such work hicrselforthroughhis f r
tx CROUP, RES.UNITS
banding-
int is w1mwithinnetearrecurplfere.
sale.If,
q ✓
howwecshe illhav l the ur Mpmvementtssathe did not Yenofcnmole fodhe owner-
builderwill have the beaten ufprovingthat M1edidnot builder improv<for puryou of TTy Y) �-
mile.). QTY. PLUMBING PERMIT FEE
❑ 1.as owner oDha property,am exclusively contracting with licensed contractors to RAO APN
construct the project(See.7Oa4.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Ww.«snoupplyman ownrofpmpenY whobuildxorimprovestM1crton,end k !-
who comructsfor such projects with a contmeor(s)licensed pursuenuo.he Contractors ALTER-DRAIN&VENT-WATER(fiA) _ FEE SUMMARY
License Law.
E] rec
I an exempt under Sec. ,B&P C for this on BACK FLOW PROTECT.DEVICE OUTSIDE FF.F,S
SANITARY Y N
Owner Dae DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT is
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby affirm lha l have a certificate ofconsem to self-insure,or a certificam of FIXTURES-PER TRAP .a U-1#
t Wmkes Comecnsation lnvurunce oracenificd copy lhereof(Seo.JS00,WDC.)whicM1 PARK FEE N
covers all employee's under this permitGAS-LA.SYSTEM-]INC.40lITLEfs ;CF rN
Policy M B NO ISIO FEES
Company GAS-EA.SYSTEM-OVER 4(EA) 1'IANCHE
❑ Cenifiede.pyNhembyftunished.
❑ Certified copy is fled with the city inspection division. GRFASEpNDUSTRL WASTE INTERCEPTOR GR,46l.kaFLE I r
CERTIFICATE Of fiX1i PION FROM WORKERSGREASE TRAIT 5011-S FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is marine hundreddollam(E100) SEWER-SANITARY-STORM EA.200FT. ELROY FTiE
or less.) NN
I cenily Ont in the unlimmmuccofth,work for which this permit is i.ssued.l shall WATER HEATER WNENT/ELECTR
not employ any Person in any manner so as to become subject to the Workers PAID
Compensaionlawsnf Cmlifomia. Dam WATER SYSTEMfMEATING Dam Receipt
2is
Applicant
z NOTICE TO APPLICANN:If,offer making this Certificate of Exemption,ynush..Id NEW RESIDENTIAL PLMB, SQ,FT. TOTAL:
FbecomesabjecIin the Workers Compensation proO,ansofthe laths,Code.You must
� > fumhwith comply with such provisions or this permit shall be deemed revoked. BUILDING ITE
OW.. Q CONSTRUCTIONCONSTRUCON LENDING AGENCY SEISMIC FEE �r
D z Ihereby affirm that there is a construction lending agency for the Performance of L: ELECTRIC ?
V C) the work for which this Permit is issued(Sec.3097,Civ.C.)
lenders Name Ph MB G LE F Isnders Address QTY. MECHANICAL PERMIT FIEF
0 U 1 readily that 1 have rend this P,sicilimi and state mal he above information is M C A (CAI.PE
Wentreat.Iagr«mcomply with all city and mumy oMinan¢sand state laws relatingm PERMIT ISSUANCE
E" n' buildingeonstraction,and hereby authors,representatives ofthiscity to enter upon the
above-mentiond n for inspection ALTER OR ADD TO MF.CII. CONSTRUCTIO TAX
V z profanity pec per,leu
(We)ogrcc m mvo,indemnify sed keep harmless the City of Cupensts against
liabilities.judgmenu,coos"expense
wNch may in anyway accrue against said City AIR HANDLING UNIt'('TO IO,IXNI CPM)
in n quence of the 1p ofthis permit.
UZ/ I 4 6Qi"7 L14- AIR HANDLING UNIT(OVER HU000CFM)
( /7
fiignawrc of Applieen ontrattor Date EXHAUST HOOD(W/DUCT PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) ate Receipt M
Will the upplicam or future building occupant store or handle bzeandous material (EATING UNIT(OVER I W."BTU) T
m defined by the Cupertino Municipal Code,Chapter 9.12,rind the Health and Satiety
Code,Section 25532(a)9 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
} S�Y CIE/DATE
Will @etmpliwm nrfumrcbuildingnccupam useequipmem ordevittswhichemit BOILER-COMP(3HP OR IIIO,fgO BTU) /
h mous air contaminants as definW by the Buy Acta Air Quality Management BOILER-COMP(OVER IfN1,00)BTU)
inner?
JUN 1' 94
❑Yes ❑No NF,W RESIDENTIAL MECH. SQ.FT.
I have mad the haseemous materials requirements under Chapter 6.95 of the
California Health& be y Code.Sections 25505.25533 and 25534. I midersmnd that 611 T yr wr-"n I B4 V
othe building does not currently have a tenant.that o is my responsibility a notify the
ceupam of the res not co ins tly aM1 must bo con prior m issuance of it Conifiwm of
Occupancy.
Owner or aumuriud ngcm Dam T ISSUED BY: _ __ Wk
OFFICE