26840 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fl I.ISINU-1A A: ITi AI. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL g'N /� /14 O
BUILDING DIVISION —,.DIN(;PROJEC'TIDEN'I'IFICCLVX
I'ION
BUILDING ADDRESS: ,� SANHARY NO. APPLICATION SUBMITTAL.DATF.
NIT# LOT It
OWNIi AMI?: PHONE.: T C N MP LICJSO:
Z a(J NIC CONTROL
CACAJ t
UICHU'Ii TENC NE iR: LIC NO: tS$� rY �-s ❑
L 5 ...0 r\5
:ONTACIU PHONE: a BUILDING PERMIT'INFO
Q'I'Y. ELECTRIC PERMIT PEki
LI , IiLGCT PLUMB MECII
PERMITISSUANCG 6 E) 0
LICENSED CONTRACT'OR'S DIiCLARA'I']ON APPLIANCES-RES]DEN'I'IAL JOB DESCRIPTION
Most I herebyaffimuhal l am licensedundo,evisi....f Chapmr9dommcmingwith
1900Section7")of Division 3 of the Business add P/r.�1fessumsC and my license is in PANELS 1
RdE lullfnme and eIfeut
<1. LicenseC Lij&lc.# /`a�+ UI'T02IXIAMPS
y71 Date. Cuntmctor OVER(10100APS
Sy2_ ARCl Ihall e CTS DECLARATION OVER 111011AMPS SQ.FT.FLOOR AREA $/SQ.FI'.
O'zNt] lundersmnd my plans shall he used as public records.
w SIGNS ELECTRICAL
�N5dd Lidnvwl Professional
py ce< OWNER-BUILDER DECLARATIONSPECIAL CIRCUIT/MISC.
XOaF I hereby affirm that 1 am exempt from the Contractor's License Law for the
IY30.rn following reu.sen.Section 7031.5,Business and Professions Code:Any city or county THMP.METER OR POLE INST.
which marines a permit to construct,otter.improve,demolish,or mpair any strunure
prior to its issuance,also requires the applicant(ursuch germine file a signed statement POWER DEVICES
d' �p that he is licensed pursmntLto the IgmAsiom of the Contractor's License Law(Chapter !
aaxo�' 9(mmmencing with Sa:tion'lOWlof Division Dullness and lh.Tessl.ns Code) SWIMMING POO!.I3LECI'RIC l ' - VAI':U 'I' N
W_y .,that he is exempt thertfrom and the basis berheolleged exemption.Anyvlolatim of OUTLETS-SWITCHES-PI%TURES - :t
EF� Y
Section 7031.5by.any applicant for a permit subjects the applicant too civil penaltyof
�a not more than f ve hundred d.11ac.($500).
X�❑ I,usownerafthe m n mm em Io mswiihwa umtheirsolecom nation. NEWRESIDENTIALELEC'IR _S .FT. DAT 'I'YPF.CONSTRUCTION
w—m le a to v t Y 8 . E _
a3— will dmhssive,workandfileHim Con ieaotinmicese Law
ffered for sale 71044.Business
preand Prty whiobu Comlds e C.mmctm§and
Lew does or apply lf nu owner of i
own enywhobuirovi improvesihemprove encs onotinces such wnrkhimsencollfor fi through his OCC.GROUP RIS.UNITS
wnemployebuildi builed ding
provenat such lmpis sold iflue not iearmoompleered the owner-
builder
builder ,will
building Orden of enact is sold within one year or improve
for the pose o TOTAL:
builder will have the bantam Of proving that he did not buil)or improve for purpose of
ale.).
❑ 1,nsowner nhe pmpeny,am exdusivelyambnninswim licensed commuters to QTY, PLUMBING PERMIT FEEFLOOD"LONE APN
onsuum the project(Sec.904kL Busines..end Professions Club:)Tho Comment's PERMIT ISSUANCE ::::tj
License Lawdoesnot apply loan.weerof propcnywhobuilds.rimpmves thereon,and
wb.eumrarts forsuch projects with a contractors)licensed pursuant to the Contractors g1.TGR-DRAIN&VRNT-WATIiR(EA)
License Law. FEE SUMMARY
❑ I um exempt under Se<. ,Il&P C for this reason BACK FLOW PROTECT.DEVICE SID .IS
SANITARY YN
Owner Data RECFIPI'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPEcanofuNUGCLARATION SCHOOL TA% Y N
❑Workers
reby Compensation
lhmihave
rance ora ceniie cosent pyacco sal(Sec.3,n,Lab C.)so
FIXTURES-PER TRAP RF.CEII'Tp
Workers'Compcnsatiordert is Insurance ora eenlEul copy thereof(Sw.3g00,Leb CJ which PARK FIiIi Y N
rs all employee's under this permit. GAS-EA.SYSTI?M-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION EGGS
Company GAS-EA.SYSTI7M OVER 4(EA) PI.ANCIIECK FBI!
❑ 'Cenifi W copy is hereby famished.
❑ CenificJcopy,is filed with the city inspection division. GREASGONDU$TRL WASTE INTGRCEPUR GRADING FEE
CF.RTIFICATF.OI'EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection cations be cmnplded ifthe pantos is forced hundred 6o1lan($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FBI.
or less.)
I cenifytht,mme performance ofthe walk for which this permit is iaaed.Ishall WATER HPATER W/VENf/6LECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensationl.avamCelifomia. Done WATER SYSTEM/TREATING Date Receipt#
O Z Applicam
0. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NI?W RESI DENfIAL PLMB. SQ,FT. TOT L:
tIn Lot subject to the Workers Compensation provisions of the Labor Code,yon must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING IEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC ITS
Z 1 hereby of en that there is a construction lending agency for the performance of
1J O the work for which this permit is issued(Sec.30o Civ.C.) TOTAL: ELECTRIC FEE
U. Fy Lender's Nanta at PLUMBING PEI:
t-' Lenders Add., Q'IN. MECIIANICAl.PERMIT F-1111U' 1 certify that 1 have read this eplifcniort and statistical the above information is
coned. la me shall cit !count MECHANICAL PGE
gree ompywi yam ynnlinuncee unA state lows relatingm PERMIT'ISSUANCIi
U-' z build
ingcntioned on, eyfre do ouNmptaftpreeematives.fthis city menmrupmthe CONSTRUCTIONTAX
(, 7 abov(We)igree ny mmimpaction purposes. ALT[RORADUTO MECII.
•7 (We)agree Wvc,indemnify,and keep may in s the City of Captain.uperto against
liabilities,judgt ,cons and ex ses may which in any way ,
City AIH HANDLING IJNI'I'(TO 10,000 CPM)
conseque c the gmming �VJV�1'
AIR HANDLING UNIT(OVER 10,000 CFM)
Signora of ApplicanVCa1 mcmr a HXHAUS'I'1 IOOD(W/DUCU '
PAID
HAZARDOUS MATERIALS OISCLOSI I IFATING UNIT(TO 100,000 BTU) Data Rc
Will the applicant or future huilding occupant such,car handle heand.us material IIPATING UNIT(OVER Ifg1,000 B'1'ID "IY)' 1.
as deft tied by the Cupertino Municipal Calc.Chapter 9.12,and the I lealtb and Safety
Calc,Section 25532(a)1
'
0Ycx ❑No AVENTILTCS
ION PAN(SINGLE RID)
Wiftlail Iicoana Tuwrchuildin ocwi fusee mrdevices whichemil BOILER-COME(3HP OR 100,1%10 BTU) p*
ISSUANCE DATE
PP 6 pun quipmm� tl_
lazanlous air contaminants as defined by the Day Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
)inrin? q
ElYes ❑No NEW RESIDENT MIiC11. SQ.FT. AUG -81994
1 have mad the Landholders materials requirements under Chapter 6.95 of the n(�u
Caliromia Health&Safety Cale,Sections 25505,25533 and 25534. 1 tr demmuld that y
ifthe builiingdoes nm currently have atenunt,that it ismy respoasibility tonality the LIP kfVftYlj//V
occupant of the requirements which must be met prim to issuance of a Cenificam.f U
Qcupnncy.
Owner m ambori,ted agent Dae TOTAL: ISSUED BY:
OFFICE