25176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC RICAI. PERMIT NO.
BUDnlrvr.mvlsloN APPLICATION/PERMIT PLUMBING-MECHANICAL T 1`4J I`�J
UILDING`PRO.IEcr IDEN'I'IF'ICAI']ON
UILDINGADDRSS: \ SANITARY NO. APPLICATION SUBMITTAL DAM
l039I
UNIT 1.o'1'# C —.e
OWNERS NAME: PHONE: CON'TRACTOR'S NAME: LIC NO: V
/C6L392 /?yL/IX/ 3 8 (r p13V1r 101--Or S 9 NIC CONTROLN
ARCHI'IECTIENGINEER: LIC NO: AD SS: G. ❑
a— k Prdt u(C--w
CONT P ONE: '
� YG
s ^3 QTY. ELECTRIC PERMIT F.13 BIJILDINGPEItMITINFO
IW RLDG I:I.F.CT I.UMD MEC i
PERMITISSUANCE
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCIiS RESIDCNTIAL JOB D]SCRIPrION
O d'Z Ha ebyoffirmlhatlem licensedunderpmvisionsofC pter9(commencingwith
Poo Section 7")of Divist a.3afthe Businessand Professions Code.and any license is in ppNH
K full face and effect. ,rV'y,RV�]
<,, 1.lemnao Class LIc.#
,,i y DateCc mrs nor
20o`ritZ ARCHITECTS DECLARATION _ ER 10(10 AMPS SQ.In'.Il. RAREA $/SQ.FT.
O Z— Fundamental my plans shall be used as public words.
rQEn ; SIGNS F.LF.CI'ftICAL 1
K Limned Prnfcsnional `
y e'6 de,OWNER-BUILDER,Inoamr DECLARATION SPECIAL CIRCUIT/MISC.
firm
4aU I hereby afexempt from the Commis Co License Law for the
fallowiSon Whichnimmen.smail 1.7031.5,riselm .alkinss and Professions Code:Anycity or county TEMP.METER OR POLE(NST.
kE �o which requires a pumtit to ennstrud,aver.Intprovo,dnnolish,or repair any atrucmm
C }� priorm its issuunce,also requites the applicant for such fumin,fileasigned,onamem POWER DEVICES
G_a pC that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
e4 9(commencing with Section 70)0)Of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is eaempnhentfrommd the hails for thealleged exemption.Any violutiun
G Sen inn 7031.5 by any appkmafor a Permit subjects the applicanuo acivil penally ` UI'LEfS-SWITCHES-FIX TURES
M< but more than five hundred dollars($500). ` (,
_o ❑ I,asownernfeepropeny.ormyemployttswie wegeaestheiraolecomprmsatien. NEW RESIDENTIAL ELIiCfR —SQ. STORIES TYPECONSTRUCf10N
y3a_e will do the work,andthe structure is not intended oroffcred forsale(Sec.]f1PI,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
propertywhobuildsvidMpavesthimp andenmmnsuchendMoroffemr Waugh hie
owneer.the
edthmwchimprocrmenearenot inrondedoroffetrd thea nw, ) OCC.GROUP RES.UNITS
however,the building burden
of anent is hath a didnot yearO rc prove for t purpose
r
-
builJerwillhavetheburdenofprovingthmhedidnetbuildorimproveforpurynsenf T t
❑ I,as ownerofthe properly,emexdusively convaningwilhlicensen contmemrslo QTY. PLUMBING PERMIT ,. FP.I? FLOOD LONE pPN
Iona ruct the project(Sec.](114,Business and Professions Code:)The Conwnur'a PERMIT ISSUANCE �r
License Lawdoesnot apply toanownerofpropenywhobuildsorimproves thereon,and
who contracts forsuch projects with acommaor(s)licensed pursuant to the Contmnor's
License Law. q{'Hft-GRAIN&VBMf-WATER(RA)) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE. O T.1)1: EES
Owner SANITARY Y N
Date RECEIPfp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCIIOOLTA% Y_N
❑ IM1ereby affirm thmlhaveacertificnie of wnsemmmlf-Insure,orncertificme of FIXTGRFS-PER TRAP RliCEwa
Workeri Compensation Insurance or a cenifie4copy,thcreaf(Sm 3gW,LnbCJ which PARK FEE Y N
covers all employre's unde ,his permit. GAS .SYSTEM-1 INC.40 IT RECEIPT#
Policy p BUILDING DIVISION FEES
Con a GA -EA, ,ANCHECK PTH fs
Cenif d copy is hereby famished.
c"is fledwitM1Necitymspectiondivision. GRJEASKilpSnmbifaT GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP. SE TR P ILS FP.
COMPENSATION INSURANCE L1I1 Tjik±
Cnissectionnesinot becompletedifthepermit isfornnehundreddollam PH(g)) SE R-gANayNnY�T E y E I�
ar less.)
Icenify that mile performance of the work for which this frobit I,issued,l shall WA HEA'1'IiR W/VPNT/ELECI'R
as employ tory person in any manner as as to bee no subject to the Workers' PAR)
Compensation Lowe of Califomie. Date WATER SYSTEMITREATING Dam e' t Z Applicator `
Z IOU
0 NOTICE TO APPLICANT.ILafmr making this CcrtiBcareof Exem ti
p oo,youu muld NEW RESIDENTIAL PLMB. SQ.Ff. TOTgL:
F H become subject round,with
it Worker's Compensation provisiorrsofthe Labor Code,you man
a , fnnliwitb comply with such pmvisions onhis permit shall be deemed revoked. BUILDING FF.F.
PS Q CONSTRUCTION LENDING AGENCY SEISMIC HE
z Ihereby affirm that is a construction lending agency for the performance of T A1,: ELECTRIC111M.
L1 0 the work for which this permit is issued(Sec.3091,Civ.C.)
0 P lender's Name a v PLUMBING FEE
L<ndc/a Addrers QTY. MECHANICAL PERMIT FLT. F27 1
LJ I certify that I have read this application and mate that the shave inf.— on is
acorrect.(agree mcomply with all city and county oNinunees end state laws relating to PERMIT ISSUANCE MECHANICALFEE
to building emsarutioa,and hereby amhomercpresentativcs of this city wen¢rupon the CONS'TRUCTION'I'AX
V Z adrve-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agV to save,indemnify and keep harmleu the City of Cupertino against
.. liabilities,judgmeam.costsandexpnmswhichmayinanywayaca.cage'bear spot City AIR HANDLING UNIT(TO 10.000 CPM)
in nmsean grunting of his pen it. Q
L /3 AIR HANDL]NO UNITHWER 15BTU)
Signa ppiicamt/Contractor Date EXHAUSTHOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURii HEATING UNIT(TO 100k000 BTData Receipt#
Will the applicant or future building occupant Wore or handle hueardous material HEATING UNIT(OVER IW,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety T
Code,Section 5532(m?Y. ❑No VENTILATION FAN(SINGLE R ,
will the uconscrnmrmetre defined by the
Areas An Quality
BOILER-COMP(3HP OR]00,00ISSUANCE.DATL
h.,trict? air contaminants as defined by the Bay Arra An Quality Management BOILER-COMP(OVER 100,000 BTU)
'Diadem
❑Yes - ❑No NEW RESIDENTIAL MECH. SQ.FT. }1
I have real avaNP
the h
ous materials requirements under Chepler 6.95 of the
California Health&Safety Code,Section 25505.23533 and 23534.1 understand that
A
if the building dkcontend, tos not cuend,have a tenant,that it is my responsibility notify the �occupant of the requirements which musthe met prior to issuanceof u CeniOcate off6Occupancy.
Owner or authorined agent Date ISSUED r