25996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO I •- R A PNRMI']'NO.
APPLICATION/PERMIT PING PROD�MECHANICAL 25996 5 9 9 6
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BUILDING DIVISION BUILDING PROJEC'1'IBRN'I'II+IL'AT1pN LJ
BUILDING ADDRESS: ■/�^— SANITARY NO, AP'PLICAT`ION SUBMITTAL LATE
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OWNI' SNA ONE: CO OR'SNAM .ICN ` r
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Cl2.GI SUR: LI O A
GNTACC PHONE: QTY. -ELECTRIC PBRITFFEE 'BUILDING PERMIT INFO
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BL ELIiCf PLUMB MUCH
PERMIT ISSUANCE ��
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION
0=z I humbyalRmt that l am licensed under provisioruofChapmr9(commencing with
00 Seaio,7000).vandef Div of the Businessland RvfessionaC and my license is in PANELS
fiat ce and effca Z
{{ mcn,c LIc.M UP T0200 AMPS
v~i<y Dam Contractor XII-1000 AMT'S
ZOyZ w CIIITF,CFS DIi-11ROVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.FT.
O Z—M I understand my plans shall be used as public records,
PLfi SIGNS ELECTRICAL � -a
�
see"' Licenxd Pmfcsninnal 7��/ 70
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xax0a V I hereby affirm Nat I an exempt from the Contractors License Law for the124 ��
t+13k set followingmacon.(Section 703LS,Business and Professions Core:Any city or county TEP.MMEILR OR POLE INST. 1{,•1,u
�; witch requires a peraut m consmuct,cher,improve,demolish,ar repair my immune r
prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W C p that he is Tic creed pursuant m the powisinns of the Connector's License Law(Chapter
2 oy' 9(commencing with Section 7000)ofDivision 3 addle Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
I _y or that he is exempt therefrom and the basis for tlte alleged exemption,Any violation of ^ r�
G Section 7031.5 by any applicant for a pennitxubjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES /`
not marc Nan five hundred dollars($500). ryEW RESIDIENt1AL ULIiCTR _SQ.PI'.
o ❑do
wrk,andeeholactinrmyemtende swi then(sasthei(sole campBusinen, STORIES 1YP8 CONSTRUCTION
yam willdo the wart.andthesoContisnm intendedorLa offered cale(Sec.1.am owner
Lassen r—
and Professions Code:The Cotnruaors License Law ones not apply m rt owner of
onpenywyces.dsorimpmvesth improvements
messuch work edoraelfm through his OCC.GROUP HIiS.UNITS
own employees,provided that such improvements are not intended ocpletioA foe sale.If,
however,rN<ave the burden of poem]shat he id one yemorimproesifn,theawnn-
b le.). will have the burden of proving that he did not build or improve for puryosc of
ales).
❑ I,00wnerof Nepropeny.umexclusivcly. contracting with licensed contractors in QTY.� ',UMBING PERMIT FEE IT.00D'ff3NU ANN
consumes the project(Sec.7044,Business and Prefesstom Code:)The Connector's
Licensel�wdoes notapply to an ownerofpropeny who builds or improves Nanton,and PERMIT ISSUA
whocnmmcls for such projects with armem:mr(s)licensed pursuant to the Contractor's ACIT3R-DRAIN&VEND .R(HA)Licenac U.. ) FEE SUMMARY
❑ I em exempt under Sm. ,tl ffi P C for Nis reason BACK Fl. .DEVICE OUTSIDEWES
SANITARY YN
Owner Dae RECEIPT.
WORKMAN COMPENONDECLARATION DRAINS-FLO F.AREA.COND. SCHOOL.TAX Y N_
❑ Thereby affirm Nalhavw certificete m of of continuo sal Ginsure.ecru certificate of PIXTURPS-''Eft TRAP CCIiIPI'.
Warters'Compansation lnsumncc ora ceniOeJ copy thereof(Sea 3gllfl.Lob CJ which PARK ME N
covin all employed.mder,his.crinis. GAS-FA.SYSTIEM-I INC.40 S RECEIPT.
Policy. UILDI DIVISI NIMES
Gmtpany GAS EA,.SYSTEM-OVIER4(EA) PLANCIIEC E
❑ Ccnified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GRPASEPNDUSTRL WASTE INTERCEPTOR GRADIN IN, q
C17RI'IFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP SOILS O ��
COMPENSATION INSURANCE
(']Itis section need not Be,completed permit is for one hmdrr4dal]ars($101p SEWER-SANITARY-S EA. LNIER FEE
m icssd
I certifythn intheperfotmmecof Ne work forwhich Nispermit i,issued,Isbell WATER HEATEAW ELECT
not employ my person to any manner as to become subject to the Workers' PAID /F
O z Compensation Lnwsof Califomia. Dare nn WATER SYSTE TING Dote ecipt. CCJ7 �W
Applicant
Z 0 NOT ICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW lidii AL PLM SQ Fr. TOTAL:
(q become subject o the Worker's Compensation provisions ofthe Labor Code,you must
7 forthwith comply with such provisions or this permit shot[be deemed rcwkad, BUILDING FE d r..si
0. [] CONSTRUCTION LENDING AGENCY SEISMIC FEE `O
V z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
the work for which this permit Is Issued(Sec.3097,Civ.CJ
Lir (r Lender's Name 7 e y 0.
0 U Lender',Address QTY. MYCHANICAL PERMI'P - FEE PLUMBINGFEE
W te 1 cenify that I have read this application and seem that Ne above information ict� s
correct. I agree to comply with all city and county ordinances and state laws relaingm PERMIT ISSUANCE MECHANICAL FEE
Ll) huilding construction and hereby radiation representatives ofthis city to enter upon the CONS'IRUCTION'1'AX
V Z above-m ALTER OR ADD TO MECIi.
live -._I ,..._ City of Cupcnine,against
Iiii' stsanJ expen w1mey inns a<crueagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
rise methe hiapmmt.
Z AIR HANDLING UNIT(OVER 10,000 CFM)
Signew Dam EXHAUST HOOD(W/DUCq PAID
I IAZARI OUS MATERIALS DISCLOSURU HEATING UNIT(TO 100,000 BTU) Dae Receipt.
Willfieapplicloom fnture building occupant some or handle hovordo.,material HEATING UNIT'(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 91 12,and the Health and Safety
Code,Section 23572(q?
❑Yea 13 No VENTILATION FAN(SINGLE RESIDE
BOILER-COMP THE OR 100,000 BTU) ISSU9y CEg UM
Will the epplicanmunts re building by the Bay equipment unlit Managemeelwhich nt I+ A
hmtrict? air mntandnanu m defined by the Bay Area Ah Quality Management BOILER-COMP(OVER 100,000 FITU)
®OiatriaT
11 Yes ❑No NIEW RESIDENTIAL MF.CII. SQ.Ff. MAR a�2 Y 9 w�s99
74
1 have mad the ha>aolous notherials requirements under Chapter 6.95 of the
California Health&Safety Code.Section.25505,M573 and 25534. l understand that CITY ser Gar
if the building docs not currently have a moral,that it is my responsibility to notify the (�
ocntpunt of the requirements which must be met poor in Issuance of it Certifiram of
Occupancy.
Owner or euthorved agcm Dam TOTAL: ISSUED BY:
OFFICE