26967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R17rt'DiM1Y'-EI"E'rRICA' PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 26967 6 9 6r 7
IIIIILIIING PRO.IECI'IDENT'IFIC.A'1'ION. v
. INGG ADDRESS: T SANITARY NO. APPLICA'T'ION SUBM�I'TIAL DATE
1 0 9 .-. O H 1 A / e✓C /S UNIT# LOT# -�J 11-2/q r{
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: )
1 > r G�r.110 'S t r PCC CONTROf.p
I1 \RCII I IHC'FIENGINEER: LIC NO: RESS
x713 /2 c7c e.-z r .a . e—
a� Sri
CONTACT: PHONE: r '.'3 P+ x
F- QTY. ?(r r a£LECTRIC PERMIT'.; PEE BUILDING PERMPP INFO
`""`a E fi i '4>•Y �BL�D�G# ELECT PLUMB MECH
x
PERMIT ISSUANCE t / pa�_ �� 0 ��f,r
J!�
LICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL. / JOB DESCRIPTION
py.Z I hcrcbyaarmtbm lam licensed underptovisionsrf Chapur9(corrunencingwit
� 0 S«tion 00(1 Division 3 of the Business and Professions Code,and my license is in PANELS
pd W C Lau force ane effect. (� �� ����, C/ �� ^ _ -
FZUty I,icensc ClassLic.#�s2a1CLll.al UP T0200AMPs VF/►l`:t/�T�-",`
yOy List t^_¢fes Cmcmm a 0FirC{ 201.1000 AMPS
ZQyZ ARCHITECTS DECLARATION J OVER IOOO AMPS SQ.FT.FLOOR AREA S/SQ.I.T.
OZ-I] tun and my grans shell be usedm uhlic rccoNs.
E.,y ; SIGNS ELECTRICAL
r nse ntfesvunal
OWNCR-BUILDS TION SPECIAL CIRCUIT/MISC.
'�3ay hereby affirm that 1 an exam a Contrecmr'e License Law for the
�nr11 following rwum.(Saban 7031.5,Business and Professions Code:Any city or county TEMP.MEILR OR PoIE INST.
of which vouches a permit to consumer,alter.improve,demolish.or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed dammeat POWER DEVICES
Qthat he is licensed uu
pwsmm the provisions or tract
o Comors License Law(Chapter
0'Wp 9(commencing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
n_ orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTI/RES
f-Z_Q Section 1031.5 by any applicantfora permit subjects the appllessome civil penalty of
of more than five hundred dollars(5500). NEW RCSIOENTIAL ELECTIt -SQ.FT.
F O STORIES TYPECONSIRUCTION
� m n❑do(he
wnemR thextreny,ormyempinyecswidmeed sasthei(sole compensation,
will dothewons Code:
The
emrclstors Liceese La do es not apply to1an Business
and P ty soh ons Code:mpr vesmaContracsn'.License Law docs not apply lf an owner of
is
ownpropenywroms,rommmprovesthereomanmentsit onotiniwork hirnscasultmughhis OCC.GROUP RES.UNITS
employees,p building
or i pr suchimprocld within
it arenot intendedmplferedTorula. r-
huilderwillhawever,the v l tingnrimprovemcnt issoldheiii act botar ofcompletion,thepose of
builder will the burden ml proving that he did not builA or improve for purpose of
s❑ Ins ruf the contractingpmperty.umendmrvdywith licensed contmcm t QTY. s'}#fit. PLUMBING PERMIT' FCB+ i PLOOD ZONI: APN
onswd 0 empr.Imt(Sec.01144,Business and professions Cod J The Cuntmnors
License lrwdoes not applym anownerofpfopmy who builds or improves therean,end PERMIT ISSUANCE
whocommets for such projects wit acomrnetor(s)licensed pursuant to the Contractor's ALTER (EA) r;
License Low. FLC SUMMARY
❑ 1 am exempt under Sec. ,li&P C for this reason BACK FLOW PROTECT.DEVICE UTSID. :1:
SANI'T'ARY YN
Owner Dam GRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I bereby affirm that l have acertificareofconuntto self-insure,oracertifcamo' 1 IT�RES-PER TRAP RECEIPT#
Workers'Cnmpensation Insurance oracertifinl cnpY terenf(Sec.3800,Lab CJwhich I PARK FEE YN
i covers"Ilemployee'a under this permit. RECHIP #
Policy# ' GAS-EA.SYSI'EM-1 INC.40UTLETS BUILDING DIVISION FS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK PER -
❑ Certified copy is hereby famished.
❑ CertiliM copy is filed with to city inspection division, GREASQINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIII RAP
COMPENSATION INSURANCE V,II `�' SOILS T'L'C
(This section need not be completed Bible permit is for one hundred dollan(SI00) SEWER-SANITARY TO ENERGY FEE
or less.)
I certify that in the Performance of work for which this permit is issued.)shall WATER HEATER WIVAr
not employ my person in any manner so as to become auhject to the Worker. 1. PAID
Compensation Lawsof California. Date WATER SYSTF.M/IREATING Date Receipt#
O Z Applicant
Z 0 NOTICE TO APPLICANT:If.after making this CcniHce¢of Exemption,you should NEW RESIDENTIAL PLMB. VTUIALE-' (q became subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked BUILDING FEECONSTRUCTION LENDING AGENCY SEISMIC FEE
ZDZI herchyaffinn tahem is a crecom tion lending agncy for tc perfomnnceoL ELECTRIC FEEUC) to work for which tis Permit is issued(Sec.309),Civ.C.)tiLenders Namea, PhUMBING FP.F.w0 FLewerserbym. QTY. ' '' MECIiAN1EAl.PT:RMIT .PLCV1 candytet I have read tis ity a dcou end elatethatthe above aws atlatio tbuildingconnr Loon,complyand with ellcity andcounsentonesoftismium.and my he entr upon the PERMITISSUANCE MECHANICALPEF:
_ Z building cnnswdiogand hcrtbyaution pmprtunutivesohhiscirymemn upon the CONSTRUCDONTAX
L) Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH. 1
(We)"gree m save,indemnify and keep harmless to City of Cupertino against
I"so
iit.
ca'
'nI mens,costa and expenses which may in any wayacemeaguinstsaid City AIR HANDLING UNIT(TO 10,000 CPM)
cc of ine grunting of tis permit
AIR HANDLING UNIT(OVER 10,"CFM)
Si fApplicerUCmm tort Date [MiAUSTHOOD(W/DUC) PAID
HAZARDOUS MAI L'RIALS ISCLOSURH HEATING UNIT(TO IW,N)l BTU) Dam Receipt If
Will the applicant or future building occupant smm or handle hamrJmis material tIEATING UNIT(OVER IW,110U BTU) TOTAL.
as defined by the Cupertino Municipal Code,Chapter 9.12.and to Health and Safety
Code,Section 23532(a)Y
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(JETOR ItIg0f1t1 It ISSUANCE DATE
Will I'Fm applicumoffumrc building by die 8,equipment "alit Management P [f 8 ITT
nallom.air contaminants es dcfinN by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(100 BTU) V- !Y6 IJ'
Disoici!
❑Yes ❑No NEWRESIDCNTIAL MECH.-SQ.FT. QC11 - 21994 199 zr
I have read the hmanlous materials requirements order Chapter 6.95 of the / JCr ls1y(�
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that n V.�e/�/Twy�/�
if the building does notcurcwy haves tcned.donu is my amponsibiliryto notify to bll Ur wro,r
occupant of the requirements which must Is,met prior to issuance of a Cenificam of 11[1
Occupancy.
Owner mawarized.,cut Dam T< ISSUED BY:rn
OFFICE