26923APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINOBTm1.IN'11 - ELECTRTCAI.
APPLICATION/PERMIT PLUMBING - MECIIANTCAU
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMITNO,
] C n <�
G V G J
26923
BUILDING ADDRESS :
SANITARY NO.
SSUUBMITTTAi
LL /✓/1
/ 6 �J� f 4- /LGP UNIT. LOT
,LDRII
/APPPPPLICA'HOONN
a/��(�
V' _
O ERS NAME: PHONE:
P a
CO TRACTOR'S N 1G LI NO:
& y
NIC
❑
CON IKOI.a
'ARCI{I 'I!C'I'/ENGINHER: LIC NO:
AU iss:
L
CONTACT: PHONE
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLU��IfB MECH
PERMIT ISSUANCE
11El
LICENSRD CONTRACT' OR'S DECLARATION
I herby affirm that l am licensed underprevisionsuf Chaper9 (commencing with
APPLIANCES- RESIDENTIAL
TOB DE ON
J Stereo 7") of Division3nf the Business end Professions Code, and mylicenu is in
— full Tome and dfec
LLiceneti Lic.N� `�
o Date Commaor
pprypUS
UP T0200 AMPS
' -
- 1IO AMPS
ARCHITECTS DIi ARATION
� 1 unJcrsbnd my plans sM1a11 be used us public records.
OVER 1000 AMPS
OVER
SQ IT. FLOOR A ' $/SQ.IT.
SIGNS ELECTRICAL
I' NO\VII
1 J
License] Rafcssionnl
OWNER -BUILDER DECLARATION
I hereby affirm oar I am exempt from the Comractnr's License Law for the
o fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit m,momw, ,slur, improve, demolish, or repair any suumum
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POUR INST, n n
_
C prior to its issuance. also requires the applicant for such permit to file a signed statement
POWERDEVICFS
r r^^
j that he is licensed pursuant to provisions of the Contrecmre License Law(Chapter
4 9(commencing with Section700B) of Division 3 ofthe Business and Professions Cade)
or that he is eaempuherefmmand he basis for the alleged exemption. Any violation of
Section ]1131.5 by any applicom for a mm, subjects the applicant as a civil penalty of
not mac than five hundred dollars ($500).
❑ I, asowneroOhe n
prapc y,orm
e
I
1 1
SWIMMING POOL ELECTRIC \ A
^ ALIIATIO
STORIES TYPE CONSTRUCTION
OUTLETS - SWITCHES - FIXTURES
—
NEWRESIDEb7IALELECfR _ Q.IT.
044. Busmen,
o will dothework, and theruucmmis not Liflense awdofarsale (Sec.
of onceyedorofemd for sale Easiness
and Prlywhions to sm
Contractors License Law does not apply m nn owner
iof
ldsminm. s
progeny who hulldsorlmnnrvce thereon, and whndnes such work him;elfor lhroughhf,
m;,provi far
ownever,
msorcneyear
OCC GROUP RES. UNITS
h or improvementsold fcompffemd
howeer, will avec a burden efrmem issoldhe id noney<ar of improve foron, the owntt-
owneL
builder will have mite burden of proving that he did not build or improve for purpose of
TO.I.AL
QTY. PLUMBING PERMIT FEE
sale.).
❑ Las owner ofthe property, am exclusively contracting with deensea ormmmors n
.
FLOOD ZONE APN
consumer lbs project (Sum. 7(W, Business and Profession; Code) The Comment's
License Lawdes, nompplymmmowne,id prnpcny whobuildsorimprovee throven.anJ
PERMIT ISSUANCE �.
whacerawero for such projects with a comrecoods) licensed pursaam to the Contractor;
License Law.
ACIER-DRAIN@VFM-WATER EA
( )
PIiE SUMMARY
❑ I am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICEISTD
E.
'1'ARY
Owner
DRAINS- FLOOR, ROOF, ARIA, CONE.
FIXTURES PER TRAP
SAN] Y N
RI?CEIPI'q
WORKMAN COMPENSATION DECLARATATION
❑ Thereby affirm thus lhuveerenificam ofrnuscm mulLins...... cenificmeof
Workers'Compensation has ... to ora cerificicopythereof(Sce. 3800, Loh C.) which
versull coma
Policy. /SOdi
SCHOOL TAX Y N
PARK
PARK FEE Y N
RIiCEIPTIt
INCAOUTLS
GAS- EA. SYSTEM -1 ET
BUILDING DIVISION FEES
Com TT
GAS - EA. SYS'T'EM -OVER 4 RA)
PLANCHIiCK FEE
Ceeilied ropy is hereby fumisM1ed.
ID Cen
Cenificd copy is filed aid, the city impwtion division.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING IEE
CERTIFICATE OFEXEMPUON FROM WORKERS'
COMPENSA9'ION INSURANCE
GREASETRAP
SOILS PIIS
SEWER - SANITARY - STORM HA. 200FT.
ENERGY PER
.(Ihkatelon need not he completed if the permit is for one hundred dollars ($100)
or less.)
tum T EA'TvR W/VENT/T:LECIR
I certify that in the performance ofmite work for which Ni; permit is issued,(shill
not employ any person in any member so as to become subject to the Worker
CompensmionJ.awsof Cnlifomie. Data
AppLcnnt
WATE STER TREATING
PAID
Data Rece' t q
NOTICE 10 APPLICANT. ILafer making this Cenifcme of Exemption, you should
become subject to he Wmkc/s Compensation movisioo.fthe Lobar Code. you most
IFIRESIDENTIAL PLMB. SQ. M'.
TOTAL:
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING PER
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that hem is a construction lending agency for the permarmocc of
,be work far which this permit Is hatted (Sec. 3097, Civ. C)
Lenders Name
TO -
'A
F.LECI 'RI -
Leaders Address
QTY, MECHANICALPERMIT FEE
PLUMB G
I certify that 1 have mad this application and state that the above information is
,PERMIT ISSUANCE
MECHANICALFE
correct. l agree to comply with all city and county ordinances and stare laws relating to
building consomelion, road hereby someone repmandidves of this city to enter upon the
above-mendoneJ n far inspection purposes,
props y eposen
ALTER OR ADU'I'O MECI{.
CO'S 110 AX
(We) ogre to save, indemnifyandkeep harmless the City Cupertino against
4—
liabilities,judgmen is nndexpenses which may loony way accrue aguimt said City
r
AIR HANDLING UNI'1'(TO I(I,IXq CFM)
I con gnenc the granting tti perms.
AIR HANDLING UNIT (OVER I(hOW CFM)
X/s L^/ a /
, Ii � V � RLI
Na
Sigeto.W. �erano//Ca�nlnR4or Date I
HxI IAOST HOOD(W/DULT)
PAID
HEATING UNIT (TO 10000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
ate Receipt.
Will the applicant or future building occupant store or handle hazardous material
as defined by the Considine Municipal Code, Chapter 9.12, and the Health and Safety
❑EATING UNI'1'(OVER 100,000 BTU)
'q .
Godo, $cclimn 25532(;)1
❑ Yea No
❑
VFNTILKTION PAN (SINGLE RESID)
Will the nroura m ar building use ordevices which emit
BOILER - COMP (31If OR 100.0i BTU)
SUANCE DATE
t, as by he
hazardous air contaminants as defined by the Bay Area Air Quality Munagintent
Area Ali
DisViclP
"1 p ,
HOLLER - COME' (OVER 100,000 BTU)
_
❑ Yce No
11V
T� M
NEW RESIDENTIAL. MUCH. SQ. I.I.
1 have read the hazardous materials requirements under Chapter 6.95 of the
••
1994
California l lcallh & Safety Code, Sections 25505, 25533 and 25534. l understand that
J
Am
__
if the building does not currently have a tenant, thus it is my responsibility to notify the
occupant of the requirements which must he net prior to isauunce ora Ceni Note of
Occupancy.
CITY U� iJ IN CIi I INN
ISSUED BY;
Owner m awhor msi agent Date
TOTAL:
OFFICE