27151APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
EOILDING-ELEC MICAI,
CITY OF CU MECHANICAL
..IIUI4DLU PLUMBING
BUILDING DIVISION APPLICATION/PERMIT PING PRNG-MECEANIFIC
PERMITNO.
71 C4
1 1 5 1
ING ADDRESS: /l/win/ P
2 ` 676 �q'c *ve UNIT If LOT#sss
SANITARY NO.
APPLICATIONSUBMITTA�LDAATE
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OWNERSN9 doo a53-1 16
TRACTOR'S'tc f -e k 9&,-V,tL 5 67 C
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7 Nrc
❑
ONTR`Of/.#
[RCHITECT/LNGI ER: LIC NO:
RESS:
pvBoK 232-7
t
CONTACT: PHONE:
PSS Bu
Q Fg ��ss�tx ELBGTRIC PERMIT," x } * z ; } 188
"#' ??i§xvP.9'C rdfr xE't"`
I - € y x ?=l'y BUILDINGTERMIT4STO .
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
❑ ❑ ❑
WOO
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Fzly
,Z0.
Z O D
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed unduprovisionsofChapmr9(commencing with
Section 7000).(Division3.fthe Busimssend Professions Code, end my]feen, is in
full home and effect^ / '� _77
License Class G �/6 Li
Date fO- - Conhamor 5_I'C F SDI!/jC
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
ppNLL9
UP T0200 AMPS
201 1000AMPS
ARCHITECPS DECLA ATION
�
I unde d as I' Ns.
OVER 1000 AMPS
SQ, FT. FLOOR AREA
$/SQ. IT.
SIGNS ELECTRICAL
r h.. ®sills
ue 'e al
EDC O, O
W 3 W h
,OWNER -BUILDER DECLARATION
I hereby affirm that I sm exempt from the Contractors License Law for the
following reason, (Section 7031.5, Business and Professions Code: Any city, m county
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
�
W QO
0. QC
which requires a permit to construct, alter, improve, demolish, or repair my structure
prior to its issuance, also requires the applicant for such permit to fle a signed statement
that he Is licensed pursuant to the provisions of the C.ntrector's License Law (Chapter
9(comoorm Nth Section 9000) of Division 3 of the Business and Professions Code
9w )
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
4
t]
or that he is exempt and the basis for the alleged exemption, Any violation of
Section 7031,5 by any applicant fora Permit subjects the applicwt to a civil Penalty of
not more than Eve hundred dollars ($500).
❑ Lasnwnerofthepropetty,ormycmpinyeeswith wages aztheirsolecompensation,
OUTLETS -SWITCHES - FIXTURES
NEWRESIDENTIAL ANM .FT.
STORIES
9'1PECONSTRUCTTON
a 3•-
will do the work, and the stmcmre is not intended oroffered for sale (Sm. 7044, Business
and Professions Code: The Contragors License Law does not apply to na owner of
pmperty who builds or improves thereon, and who does such work himaelfor through his
own employees, provided that such improvements are not imended or offered for safe. If,
DEC. GROUP
RES. UNITS
TAE:
however, the building or improvement is sold within oneycaroexample[ion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
'. .'" ...
QTY,' {,,, NPLUMBING PERMIT,` PER,
'alar.
❑ I.asownerofthepmpeny,amexcluarvelyc.ntreumgwimlicensedwnlraem t
.Y the project (Sec. 7844, Business and Professions Code:) The Contractor's
FLooD zorvE
APN
License Law dons not apply than ownerofpropeny wh.buildsorimprovestomease, and
PERMIT ISSUANCE
whocoatraets for such projects with a eouuacto(s)licensed pursuant totheContracter's
License Low.
ALTER EA)
- -
PEB SUMMARY
❑ 1 em exempt under Sec. , B & P C for this rcazon
BACK FLOW PROTECT. DEVICE.
OUTYIOE FEES
Owner Dam
DRAINS -FLOOR, ROOP,ARPA,COND.
SANITARY N
RECEIPT #
WORKMAN COMPENSATION DECLARATION
❑ Ihereby lhml[Ove copyther,l Ginsure,or of
SCHOOL TAX Y N
RECEIPT#
ance ortifeamof
peaaffirm
Lab C.)cate
Worker Cmployee'iunderthisermit. certified copy Nere.f (Sec.3g00, Lab Cr which
FIXTURP.S -PER TRAP
PARK PEE Y N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS ���
avers all employee's under this permit
Policy #
RECEIPT#
BUILDING DIVISION FEES
Company -
GAS - EA. SYSTII-OVER4 (EA)
PLANCHECK FEE
❑ CeNfred copy is hereby furnished
GREASIVINDUSTRL WASTE INTERCEPTOR
GRADING ME
❑ Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS PER
SEWER- SANITARY, STORM EA. 201
ENERGY ME
(This section readout be completed lfthepmmh is forone hundred dollars (1100)
.nese.)
W .AMR W/VLNT/ELECTR
Icertify that the perfr.saofthe work for which this permit is issued,]shall
not employ any person in any promer so as to become subject to the Workers'
PAID
O O
zyap
Compervidwalawsof Celifomia. Date
WATER S3lIMM/1'REATING
DateReceipt#
NOT'ICE[TO APPLICANT: If, after making this Certificate of Exemption, should
become subjecttothe Worker's Compensation provisions of Labor Code, you tors[
ESIDENTTAL PLMB. SQ.
TOTAL:
.~I;�).
Lei 7
(�
UZI
O
hwithc
forthwith comply with such provisions or this permit sbal]be deemed revoked.
CONSTRUCTION LENDING AGENCYISMIC
hereby affirmthat [here is a construction lending agency for the performance of
the work for which this Penni[ is issued (Sec. 3197, Civ. Cr
BUILDING IEE
FEE
T
ELECTRIC FEE
~iAt
u" F
V
r�'t 0.
U Z
C)
Lenders Name
tender s Address
I certify that I have read this application and sate Net the shove nformauon
c.rrecl. Ia recta cam [h all cit dc.um Ninances and saa laws re]atin to
e ran yn g
g pdherebyIves obhis city toen[er upon the
al,ev i-meng ntionedti.gand her inspection purposes.
purposes.
above-mentioned properly formnify
x x : -
QTTI''. ` ° * MBCII,4NICAL PERMIT x y 3 ^ PE8
1' ' %) "' " *" r t -
PLUMBING FEB
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save. Indemnify and keep hnrmlese the Clry of Cupertino against
and
Ilahilities,judgments, costs vnIanMhmayy way accrue against said City
AIR HANDLING UNIT ITO 10,000 CFM)
' /q��-J7 _,
VVDate
AIR HANDLING UNIT (OVER 10,0071 CFSE
Signmure . pplje nt/Contructor
/
EXHAUST HOOD (W/DUCIj
PAID Ci G 1
HEATINGUNIT(TO 100,000RTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Reef t#
Will the applicant or future building overprint store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 of
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(ap
❑
EIYes ❑ No
Will the applicant orfumm buildingoceupant useequipmenmrdeviceawhiehemit
azandmi air conaminams as defined by the Bay Area Air Quality Management
ROLLER - COMP (31IP OR 100,000 BTU)
ISSUANCE DATE
//
6� A
BOILER � COMP OVER 100,000 BTU
❑ Yes ❑ No
OCT
NEW RESIDENTIAL. MECH. SQ. Er.
1 have rcad'the hazardous mater
materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533.d 25534. L underhand mat
ifthe building does not currently have a tenant, that it is myresponsibility a notify the
6 12
C�(y
�((�r}�(r�/Uo)-(-.,,
-
occupant of the requirements which must ed met prior nr issuance of a CenlGcate of
Occupancy.
ISSUED BY:
a.
Owner or authorized agent Date
TOTAL:
OFFIC