26054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
B MAIN.-ELECTRICAL PERMI'PNO. 0
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION - IIIJILDING PROdNCI'111F.NTIN1a:ATl11N
54
SANITARY NO, APPLICATION SUBMITI AL DATE
BUILDING ADDRF3S:
/ UNIT# LOT
OWNERS NAT PHONE: CONTRA R'S NAME: LIC�O NA] CONTROhg
mconnie
�ARCIII'IE I GINF.ER: //LIC NO: ADDRES / 7 ❑
CONTACT: PHONE: QTY o ELECTRIC PERMIT IEE BUILDING PERMIT INFO
BLIXJ ELECT PLUMB MECH
PERMIT ISSUANCE! (� ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DIISCRIP' N
0
I hereby affirm that l am licensed underprovisionsm'Chapser9(commrncing with ,S /- ALa-, /�p�
00 Section 7000)of Division 3oflhe Business and Professions Cade,and my license is in PANELS vN
y�Z tall farce and effect r'
GG License Clas Lic.p UI'T02UU AMPS
,<c. pate HIComranor OV201-IO00 IXAMPS t' Il. RARER
ZOr,l' RCIIITECTSDECLA OVER IINNIAMPS � " �'
OZF-G Ian 'ridmyptums,hlllbeuseJ nspublic rccr
SIGNS ELECTRICAL
rn
a LicensulProfesxional
C OWNER-BUILDER DLCfARAT10NSPIiC1AL CIRCUIT/MIS .
KOy V I hereby affirm that I am exempt from the Cmdrachns License Lave for she
m30.F Section'1031.5,Business and Professions Code:An tcountyTEMP.MIiIRR OR roL 'T.
following ( Any
��0 which requir a pewit to conswn,alma improve,demolish,m rep r any esmdure POWER DEVICES
EN}2 prior to its issuance,also require she applicant for such pewit a file a signed strament
W 6 tont he is licensed pmanum to the provisions of the Commcrm I license Law(Chapter
Wq Om SWIMMING POOL F,LF,CI'RIC VALUATION
R
XOLL 9(commencing with Section l000)of Division 3 of she Business and Professions Code)
W_y .,that he is exem,parefmm and the basis for the alleged exemption.Any violation of
i•Z aSermon 9031.5by any pp11anIfo,a pewit subjects the appBConnoa civil penalty of OUTLETS-SWITCHES-FIXTURES
Sp
not mom than Ove hundred dollars(E500). NEW RESIDENTIALELECB _SQ.FT. STORIES TYPECONSTRUCfION
W1m ❑ I,asownerofNeprop y,ormyemployceswiNwagesastheirsotecoin enation,
d and Professions
and e: he Contra ctol s License L a dos not apply 9044,Business /
and Pmfessiom Code:The Contractor's License Law does not apply to an owner of
properly whobuildsorimproves thereon.andwhodcessuchwork himuHorthrough his �p(�gCUP RIi5.UN1'1'S
ever,.yeas.provio,imptench,mprovemwthinn,intnodulmorrered formula.If, / /
however,she have
the
bur improvement is hath within one year of completion,the owner- TOTAL:
builder will have the buden of proving that he did not build or improve for purpose of ,
sate.). QTY. PLUMBING PERMIT FEE FLOOD ZONe APN
❑ Las rofthe property,amexdusively contracting with ticctsudc.ohmarsa
on,truct the project(See.IB44,Business and PmPossmas Code:)The Convector's PERMIT ISSUANCE,
Licen¢Law doesnol apply toanownerofpropany who buildsmornproves thereon,and
whocontme0 for such projecuwith a commands)licensed ploommuome Contramea ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
License Law.
❑ I um exempt under Sec. B&P C for This reason BACK FLOW PROTECT.DEVICE. OUTSIDE ..S
SANITARY YN_
Owner Date RECE,PI'p
• co WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,COND. SCHOOL TAX YN
❑ I hereby uffiw thatlhaveacenificam of consenuo ulLinmre,or a certificate of FIXTURES-PER TRAP RF.CEIPI'#
Wodcrs'Compereation Insurance ora mmfied copy doccof(Sec.3800,Lab C.)which PARK FEF. Y_N_
REIVISI N
rn all empinyee'sq�r r GAS-G.SYSTEM-I INC.40UTLE'fS BUILDING DIVISION P[IS
Policyk Q�ICL ,n�ca n!f .T/nv-.nA/N /
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is Ill cmished.
❑ Candied copy is filed with the city inspection division. GREASFjINDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT10N FROM WORKERSGREASETRAP SOBS FEE
COMPENSATION INSURANCE.
Oltisecclionneuf not be completed Hine pe wit Ls forone oumdmx,da11ars(9100) S13WER-SANITARY-STORM HA.20011111 ENERGY PER
Or less.)
,cenifythatinihp manceof Ne ork rwhichshispewhieiasue ,ls It WATER HEATER W/VENT/ELECR
not employ any p s e y mann ,s a become subject to a PAID
Compensation w in. Dm v WATER SYSTRIOUR RATING pate Receipt#
O z Applicmt
z � NOTICIiTOAPPL N .IL otter mal lag his •nifcutcofExemption,yoush�uld NI:WRCSIDENTIALPLMB. SQ.PI. TOTAL:
)-+ ..-. become subject to Ne Worker's Carnival of n IF kions of the Labor Code,you must
t^ forthwith comply with such provisions or t is pewit shall be deemW revoked. BUILDING IEE - 00
FkI Q
CONSTRUCTION LENDING AGENCY SEISMIC PEG so
z 1 Imehy affiw that there is a construction lending agency for the perfommnce of TOTAL: ELECTRIC FEE
O the work for which skis pewit I,issued(Sec.3097,Civ.C.)
lender's Name PLUMBING FEE
0 F Lender's Address
QTY. MECHANICAL PERMIT FEEU I cenify Lou I have read This application and state that the above informminl is MECHANICAL FEE
versa.I agree to comply with all city and county ordinances mixture taws mhumgm PERMIT ISSUANCE
building construction,and hereby ambo' mpmsentmives of Nis city to enter upon the CONSTRUCTIONTAX
U z ubma-mentioned prop for inspeuti a p ores.
ALTER OR ADD TO MF,CII.
(We)agree to so e,' demnify like hamlus the City of Capenino against
liabilities,)udgmc Is, sl and expen swh'hmayinanywayaccrueagai stsai BY AIR HANDLING UNIT(TO 10,000CFTI)
fire.mcquenc it gr nagof Is a AIR HANDLING UNIT(OVER i(L"CFM)
Signature of licanl/Contructo D 0 EXHAUST HOOD(W/DUCI) PAIL)
I3AZARDO S ATER DISCLOSURE
HEATING UNIT(TO 100,110)BTU) Date Reccipt#
Will the applicant or future adding Occupant store or handle himardaus materia, HEATING UNIT(OVER,00,000 BTU) 'TOTAL: 5'C
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)t V HNTILATION PAN(SINGLE BESIDE
❑ aYes ❑No ISSUANCE DATE
can
Witlthcnpplit orfuam building occupant usecquipmeni ordevices which emir BOILER.COMPORPOR 1100,00(1 BTU) pg p M O
hawNous air camnim at,u defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) r �•//K`/G~S//1
District!
❑Yee ❑NO NIiW RGSIIJF.NTIAI.MECH.—SQ.FI'. MAY 2 3 199
1 have read the hemL
dels rtquircmems under Chapter 6.95 of the _
MAY a�`�
GliEI have
a ons255(15, and hapten erstend Natantebaauimg doea tenant,t tit is yre,pomaiCITY Gh l,urEMl uvU
carom of the eust prior issuance ma rtifc a of
Occupancy
em
Owmamllm .cd age to TOTAL: ISSUED BY:v_e—
/�NC�`a""n's
OFFICE