27122 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO + IL r,-ELI. TRI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL n �'I �n
BUILDING DIVISION BUILDING PROJEMADENTIFICATION L 1 L
-1 BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT# 14
WN•RS NAME: PHONE: COMI'RACIOR'SNAMB: LIC NO:
D _ .� N/C CONTROL#
•ARCHITECT/ENGINF R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: -
Y. _ - .ELECPRICPERMI'r: FEE ' BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL w
OCz I therebyaffiern that l um licensed underpmrd
visiens ofChaper 9(comencingwith JOB DESCRIPTION
�OO Section 7")of Division Sof the Business end Professions Code,and my license is in PANELS T 1...
full force and effect. �f { /JI '� .f ev
�zw License Class _ Lic.p JJA1 UPT02W AMPS '�wk- Y W `
b,<c Data Contractor 201-IBM AMPS
Z O,z' ARCHITECTS DECLARATION SQ.PT.FLOOR ARCA S/SQ.IT.
OZ—M I understandmy plans shut]be used as Public records. OVER I(XIO AMPS
P vs F; SIGNS ELECTRICAL
6 �,J Licensed Professional
49=< OWNER-BUILDER DEC1ARA'I'ION SPECIAL CIRCUIT/MISC.
qx O: 1 hereby afford that 1 an exempt from she Contractors License Law for the �1
1+131+-ro following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MITILR OR POLO INST. _0 y
E]' o, which requires a permit,.conshuct,otter,improve,demnl lsh,or repair any structure
Y�ed
m its issuance,aleort then applicant far such Permit file a signed statement POWER DEVICES
prior yuires pp permi gn
_a O that he is licensed pursuant to the provisions of the Commdors License Law(Chapter
aa�o 9(cammencing with Section 7000)of Division 3 of the Businaeand Professions Code) SWIMMING POOL ELECT RIC ALUATION
Wim or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
ZY Section 9031.5 by any appmurnfor a permit subjeco the appliam to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
ma
not more than five hundred dollars(SIMI). .PT. ,
Cm ❑ I,asownensl lhepropeny,ormyemployecs with wages us NNEW NESIDEN'I'IAL ELEC'TR eirsole compensation, _So �S RIES TYPCCONSTRUCTION
y5_ willdathework.aad the structure isnot immndealmoffered formic(Sac.9014,Business 1lb
and Professions Code:The Convector's License Law does not apply to an owner of
property whobulldsorimposes Nercon,andwhodwas such worknimselforthrough his
ownemployces,pmvidedthat such improvements are not iamaddbroffered forsale.If. OCC.GROUP RES.UNITS
however,the bui]dingorimprovemem is sold within one yearofcompleties.the owner. _ JOTAL: SZSO
boulder will have ata burden of proving that he did am build or improve for purpose of
sure.j.
C3I,wownerofthepropeny,amexclusivelycommaingwithlicens wnt=tonto QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
amnrun the prnjeo(Sec.9M4,Business and Professions Cohr)The Contractor's
License L,wdmsnotapplytoanownerofpmp rtywhobuildsorimpmves Merton,end PERMIT ISSUANCE
who contract%for such projects with o comracmt(s)Iicenmd pumuantothe Concavities
Licene Low. ALTER (EA) PEP:SUMMARY
s
❑ l innexempt ander Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTqIDC
SANITARY YN
• Owner Date RECF.IPI'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPIiNte afro DECLARATION SCHOOLTAX Y N
❑ Ihertby affirm Natl have aceniT¢me of consent to self-insure,ora certificate of RECEIPT#
F1XTI1RL5-PER TRAP
Workeri Campensntion Insurance oracenifie4vnty Ncrcof(Sa.3g00,Lab CJwhich PARK FIAT YN
covers all nn,hwee's under this permll' GAS-HA.SYSTEM-]INC.4 OUTLETS R17CEIPI'#
Policy# BUILDING DIVISION FEES
Company GAS-F.A.SYSTEM-OVEN 4(EA) PLANCHECK FEE
❑ Certified copy is hereby Punished.
❑ Certified copy is fled with the city inspection division. GREASE/INDUSTRLWASTP.INTFRCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASB TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifine permit is for one hundred dollars(SIMI SEWER-SANTI'ARY-STORM EA.200FT. ENERGY ITE.
,r less.)
I certify that in me perfommnce of the work for which Wis pencil is issued,l shall WATER HB,TF.R WNENT/ELEC'I'R
not employ any person in any mender so as to become subject to the WorkersPAID
Compensation Lawsof California. Dam WATER SYSTEMOREATING Date Receipt is
C) z Applicant
z (2) NOTICE TO APPLICANT:If.after making this Cerifictte of Esemption,you should NEW RESIDENTIAL PUMP. SQ.PC TOTAL:
p En become subject to the Workers Compensation previsions ofthe Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC ITE
� I herchy affirm that there is o construction Pending agency far the performance of (�Q the work for which l his permit is issued(See3097,Civ.C.) TOTAL: ELECTRIC FEE a 4� 0
Lenders Name
0 U PLUMBING FEC
Lenders Address QTY. d' ME key 'eFEE
U 1 cosily in.,I have read This application and smtc ihm me abase information is
correct. I agree to comply with all city and county ordinances and state laws raising to PERMIT ISSUANCE MECHANICAL FEE
I--' building construction,and hereby ammonia,repiesematism of Nis city to enter upon the
U 7 above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
rte- (We),gree to save,indemnify and keep h.la,a the City of Cupertino against
Iiahilitia.judgmentr,coss and expenses whichmay inmy way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
nsequenceofmc at agoftbis rmit
AIR HANDLING UNIT(OVER 10,000 CFM) p
Signaw App icon, am Dam EXHAUST HOOD(W/DUCT) PAID
11AZA DOUS MATCRIAfS DISCLOSURE HEATING UNIT(TO 100.010 BTU) Data Receipt is
Will the app]icant or future building eventual store or handle h umank us mammal IIPATING UNIT(OVER 100,000 B'1'lJ) '1'D0'AL'
m defined by the Cupertino Municipal Code,Chapter 9.12,and the I leal,h and Safety
Gale.Section 5u)
91
ElAY '! VENTILATION PAN(SINGLE RESct, ❑No IDI
Will thea Iicanumfnumbuildin accu BOILER-COMP(3HPOR 100.000 BTU) ISSUANCE DA'PF.
pp g pant use equipmentordevicee which emit
musicians air constructions as defined by the Bay Area Air Quality Management
BOILER-CENTIALMECH.,000BTU) OCT -7 1994
Distant?
❑Yes ❑No NEW RLSIULNTIAI.MECH. SQ.Pf.
1 have mind,he hazardous materials requirements under Chapter 6.95 of the LI I T VI V W'C11I(IVU
Culifomiu health&S,fe,y Code,Sections 255(15,25533 and 25534. 1 undersamd mat
if the building does not currently have a ronwL that it is my responsibility to notify Ne
occupant of the mandrani which mad he met poor to issuance of a Certificate of
Occup,acy, f�r� �f1...�A
Owner or mbonrN agent Date TOTAL: ISSUEDBA I ` `�' \m -`-V C(I
OFFICE