26680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HURLU
INtz.ELLL'RICAI. PERMTTNO.
APPLICATION/PERMIT PDILUMBINO.MECHANICAL 26680
14UILDIN6 DIVISION BUILNG PROJECT IDENRI
'ITCA'1'ION
BUILDING ADDRESS: �• `y Q ` ,,^ SANITARY NO. /APPLICATION SUBMI'I'I'AL DATR
SG64-KK %W Y UNIT# LOT#
OWNERS NAME: PHONE: CONNOR'S NAbQ LIC NO: C
W Y&-F5 1.- N/C CONTROL#
RCHITI?CI'/ENGINEHI: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PF;13 BUILDING PERMIT INFO
BLDGELECT' PLUMB MUCH
PERMIT ISSUANCE T1 E] 0 E]
LICENSED CONTRACTOR'SL. �r DECLARATION APPLIANCES-RESIDENTIAIUB DESCRIPTION
pCz I hereby affirm that l um licensed underprovisions of Chapter9(commencingwith
0 Suction 9(100)of Disieion 3 of the Business and Professiens Codgand in,license is lit PANELS
U<-zLll force and
Fm Lic.M UI'I'O 2W AMPS
y<y Date Contmnor 201-l0k)AMPS
F m ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.IT.
z0vsa OVER IOW AMPS
0z—❑ Iundersmnd my plans shall he used as public records.
y
Eul SIGNS ELECTRICAL
�y�CJ
Licensed Professional
xa O0. 1 hereby affrm tOWNR-B emp( from dueDER ntrec DECLARATION SPECIAL CIRCUIT/MISC.
's License law for the
t513kM following reason.(Section 7031.5,Business and Professions Code:Any city orcoumy TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,ter mpuir any snuctum
A;!(r� priorm ire issuance,elsnmquiresthe applicant for such pesmiuo fil<nsignW smmment POWER DEVICES
W_a_00 that he is IicensW pursuant m the provisions of the Commctors License law(Chapter
aao� 9(commencing with Section]000)ofDivision 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
❑y or that he is exempt Intefrom and the basis for the alleged exemption.Any violation of
Y
Section 7031.5 by any applicant For it permit subjects the applicant n a civil penalty of OUTLETS-SWITCHES-FIXTURES < lv^`
< not mom then Bve hundred dollars($5811).
Oo ❑ I,mownerofNepr^pent',ormyemployeeswiNwagesmtheirsolecompmation, NEW RESIDENTIAL ELFCTR _SgTORICS TYPE CONSTRUCTION
i3=e will do the work,and the structure,is not intended or offered for sale(Sm.'HN4,B usiness
and professions Code:The Cmmmb rs License Law does not apply to an owner of Ay
properly whobuilds or improves thereon,and whodues such work annielforthrough his
own employees,provided that such improvements are not intendedoroffemdforsale.If, OCC.GROUT' RES.UNITS
however,the building orlmprovement is sold within one yearof completion,the owner-
builder .will have the burden of proving thin he did not build or improve for purpose of TOTAL"'
sale.).
❑ Las owner of Oe Property,sm exclusively contracting with licensed contractors to Q PLUMBING PERM FLOOD ZONE pl'N
construct the project(See.9044,Business and Protestants Code)Tha Contmemr'x
License Law does not apply man ownerofpropeny whobuildsorimprovesnhcreon,and PERMIT ISSUANCE
whocntmebfmsuchprojeanwiNacontuctor(s)littnsedpunuantioihe Conuctoes ALTER TLA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROI'IiCI'.DEVICE OUTSIDE FL
SAN I'1'ARY Y N_
Owner Date RECEIPTp
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
I hereby affirm that 1 have a cenifcate oformem to self-insum,or a cenifeme of RECEIPTp
ns
orkers'Compcmion Insurance or a cenified copy themof(Sec.JAW,Lab C.)which tl%TURFS-PF.R TRAP PARK FEE Y N
crs all employee's under this permit. GAS-HA SYSTEM-1 INC.4 OUTLETS RECEIP1#
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4 HLA) PLANCHECK FEE
❑ Cenified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTILICA'I'E OF EXEMPTION I-ROM WORKERS' GRPASETRAP SOILS FEE
COMPENSATION LNSURANCE.
(Otis section need not be completed if Ne permit is forone hundreddollars($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this Permit is issued,l shall WATER HEATER W/VFNT/ELECI'R
not employ any person In any manner so as to beunme subject to the Worker,' PAID
Compensation Lawsof California. Dom WATER SYSTE.MOREATING Date ReceiptM
0 z Applicant
z 2 NOTICE TO APPLICANf:If,after making this Cenifcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IIT. TOTAL:
V) become subject to the Workers Compensation provisions of the labor Code,you must
a forthwith comply wilh such prorem
visiror this permit shell be deeed revoked. BUILDING
4 (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I hereby off Nat then B a construction lending agency for the performance of
O me work for which this permit is Issued(Sec.3099,Civ.C.) . TOTAL: ELECTRIC FEE
(Li pr Lender's Name . . .
� F' Lenders Address QTY. MECHANICALPHRMII F13F PLUMBING EEE
V I certify that I have read this application and state that the above information is
>a 1 mrrem.l tocool 1 with all cit and ordinances and state laws relatin to PERMITISSUANCL MSCI MNICAL FEE
agree comply city Y^ 8
L
buildingconswmion,and hereby orthicon rtpresemmives of this city menter upon the
( above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(W c)^gree m snve,Indemnify unit keep hamdna the Chy of Cu Ino ng a
'ZLIabilitinx,judgmems,costs and expense which may in nny wet'ggt;¢nen 1. AIR HANDLING UNIT ITO 10,0(10 CFM)
eyuence of the
grenti of this permit. I`/
AIR HANDLING UNIT(OVER 10,0(10 CFM)
'ignnuuco Ati tcan PAID
MI
Date EXHAUST HOOD
HAZARDOUS MATERIALS DISCISO HEATING UNI'T(TO buff"BTU) Dam Receipt#
Will the applicant or future building occupant store o Ie hazardo^s material BEATING UNIT(OVER 100,000)ETH) TOT
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)'7
❑Yes ❑No VITTHLATION PAN(SINGLE RESID)
Will rhea licanrnrfutum luildin occu BOILER-COMP(3HP OR IW,(1118 BTU) ISSUANCEDAT
o pp g he
Am.Air Quality which ) r A
zardoux nir comuminanm az defneA by the Bey Arca Air Quality Mana6emem BOILER-COMP(OVER IOO,IXp BTU
sten^
❑Yes ❑No NEW RESIDLM'IAI,MECH. SQ.FT. JUL u 6 1994
1 have read the haurdous materials requirements under Chapter 6.95 of the U
California Health&Safety Cade.Sections 25505,25533 and 25534. I understand that
if the building does not currently have a mount,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Cenificam of Ur VU 'Y II
t Occupancy. rX
Owner on authorized agent Data TOTAL: ISSUED BY:
OFFICE