26834! APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
T BU LB NC- .1.E TRICAI. PERMITNO,
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL. A C e O A
BUILDING DIVISION BUILDING Money3 26834
BUILDING
IDENTIFICATION- " L v O
BUILDINGAADDRESS:/`� SANITARYNO. APPLICATION SUBMITTAL DATE
V aJ LOT# O
OW AM PHONE: CONTRA' '$NAME: LIC NO:
N/C 1_7c
��fff CONTROL#
R dill . /EN (NEER: LIC NO: A �: ❑ /
L
- CONTACT: PHONE: Hl71CDINO PERMIT INFO
QTS'. ax.• . ,. ELBCTRI PERhIIT- -PEH
LD ELECT PLUMB
MEC 1
666 PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
0Wz I hereby aflbrd that l am licensed anderproodomro'Chapter9(commeneingwith
Fa00 Section lout)of Division 3 of the Business and Professions Code,and my license is in PANELS �#
ty F LicneClad effect. �i�1 ' v
ficenue it Lic.# UP TO 20d AMPS '� Y�IJ_-,
V, m Date Contractor 201-1000 AMPS
Fyz ARCHITECT'S DECLARATION SQ.PT.FLOOR AREA $/SQ.FT.
Z O m— 1 understand my plans shall be used as public records. OVER IOW AMPS ^ O
Oy,�'�{ 1aSIGNS ELECTRICAL
(.�Oy1+
•...J{l Cleansed Professional ` f
(� oJ6 OWNER-BUILDER DECLARATION SPECIAL CIRCUCOMISC.
U 1 hereby afford that I am exempt from the Contractor's License Law for the
¢J 3 ti v following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1" 1 which requires a permit to construct,alter,improve,demolish,or repair any structure
N poorm its issuance,alsorequires the applicant for such permitto file a signed statement POWER DEVICES
that he is licensed Pursuant o000)od svisionons the Ce Business License Law sionsCd(Chapter
)jummic. SWIMMING POOL ELECTRIC ^ yALUA910ry
a 9(oommoneing with Section L000)a[Dlvleimn3mfihe Business and Professions Coda) 1tel
motor he is exmnpuherefem and the basis fonbealleged exemption.Any viol
Y Section 70315 by any applicant for a permit subjects the applicanttoacivi wwII'of OUTLETS-SWITCH• -FIXTURES
! G nm mare than five hundred dollars($500). NEW RESIDENTIAL ELE R S .TIT.
tY � ❑ 1,mowneroftheproN"y,ormyemployeeswith wages as theirsole ompensatiom Q STORIFS TYPE CONSTRUCTION
ywill do the work,and the strocture isnotinrendedoroffered for sale(See 044,13homess
and Professions Code:The Conunctor's License Lew does not nppl to un owner of
property whobuildsorimprovesthereon,and who does such work Nm elfortlmoughhis
own employees,pmvidedthatsuch improvements ore notintenderhr ffemdforsale.If,
OCC.GROUP RES.UNITS
however,the building orimpmvement is sold within one year
pletiogtheowner- O
builder will have the burden of proving that he did not build or ve for purpose f
eelu). 1O 3 _ ii�_
❑ I,as owneroRhe propenYamexGosmelyconvoating wi Itccnsed commnm fiP6 MBINO PP. IT`b 3 ; eu MP9H. y FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions ode:)The Coatmm P RMIT ISSUANCE
License Law dues nut apply man twee, fpmperry whobull .,I vas thereon,, d
who contracts forseAn projects withnoontmetor(s)licensed u uant to the Coad 2s -
Liewe'dLow. IRR- &V T R(EA) - . YEE SUMMARY
❑ I am exempt under Sec. ,B&P C ow this reason BACK FLOW ROTEC )it I MU i FEES
SANITARY YN
Owner arcRECEIPT#
WORKMAN COMPENSATION DECLAR N I.IJIRAREkR,ROOF,AREA,GOND. SCHOOLTAX Y N
❑ I hembyaRnn that l have acertEame ufcommouto self-insure,oracertificnte of FUTURES-PER TRAP RECEIPT#
Workers'Contpensmion lnsumnoeoraccrtifiedwpy thereof(Sea.3S00,Luh CJ which
PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVP.R 4(EA) PLANCHECK FEE O
❑ Cenitied copy is hereby famished.
❑ Certified copy is Ideal with the city inspection division, GREASEANOUSI'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE /s'
COMPENSATIONINSURANCE
(This section need not be completed ifrhepermit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200II'. ENERGY FEE ex
arles,J
I certify that in he perfotmanceef he work for which this permit is issued,)shall WATER DEATHS WNEMI'/ELECI'R
not employ any person in any manner so as to become subject m the WorkersPAID
Campensmion Lawsof C#lifomia. Dare WATERSYS'TEMfrREATING Receipt#
C) 'Z Applicant
0 NOTICE TO APPLICANT:If.after rtiaking this Curificemof Exemprion,you should NEW RESIDENTIALPLMB. SQ,ET. TOTAL:
.�. hecome subject to the Worker's Compensation pmvisiuns of the Labor Code,you muer
� , forthwith comply with such provisions or this permit shall be deemed revoked. BU I GPE
[� CONSTRUCTION LENDING AGENCY
a rZ I tercbyoffirm that there is a construction lending agency for performance of
L) the work for which this parnat is issued(Sec.3097,Civ.C.) E •'IRI E e -
Lenders Name *.,a x W
Ic) ULenders Address QTY, MECHANICAL PERMIT, CCE i! PLUMBING HE
U I cert fy that I have read this app)canon and Stam ohm diastase inform ale is - MECHA21 AL FEE
correct l agree to comply with allcny and county ordinances andshrte laws relating to PERMIT ISSUANCE
lachdo,owe tructlon,and herehy amhorizerepresemntives of thiscity toenter uponrbe CON LTIQN TAX
IJ Z above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify and keep hanNess the City of Cupertino against
Iiubi li ties,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNI'1'(T010,000 CPM)
in came of the granting of this permit.
/� � AIR HANDLING UNIT(OVER BLOW CFM)
ignmure of Applicant/Contractor Dat BXI IAUST HOOD(W/DULT)
� PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TO
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)Y
❑.Yes ❑No VENTILATION PAN(SINGLE RPSID)
'
WIl the aPPlicam arfumrp building occupant ordevlceswhich omit
BOILER-COMP(3HP OR IW,OW BTU) IS A DATE
zurd 's air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) OCTQ 11994
isvicf! W VV
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.PC (s 'v
I have read the lumentans materials requirements under Chapter 6.95 of the G C tI ut- uuI'tl-{I my
i ifomla Health.9 Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building docs not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner ter aulowind agent Date ` ISSUED BY:
OFFICE