26789 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOm., 0-ELECTRICA PERMITNO.
BUD,DJNV DIVISION APPLICATION/PERMIT PLUNKING-MECHANICAL O
BUILDING PROJECT IDEN'1'IPIM[ON o
BUILDING ADDRESS: rA SANITARY NO. AP�P]LICA.TaIO'NSUBMITT(ALLDATG
V UNIT# LOTH !—,/ /4--f7
T NERSNAME: PITON CO AME: — I.ICNO ^^^"iVV/
I/NlEd`� gJi�G /S NIC CONtROI.a
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
7.80 >G.c�d �-to•�o>v> �
COM'ACf: PI10NC: QTq. i#', ELECTRIC�PEkM Tk,. * ' Vbu g '
4 +tBUICDING PERMIT INFO,
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE .� ❑ /91 El ❑
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
RKZ I hereby affirm that ism licensed under provisionsofaicaer9(commencingwith
og Section 7")of Division 3of the Business and Professions Code,and my license is in PANELS ,/'/
y�j full force and If —'y'¢�� bL��Il
F,Ztr1 Date S ss�=--f---Lic.M UP T0200 AMPS
may Date Comracm 201-I000 AMPS
ZOvs K' ARCIIITECPS DECLARATION OVER 1000,AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O Z t] 1 undcrsmnd my plens,ball be used us pahbr osemdr.
r y tzul SIGNS ELECTRICAL
6SG�J Licensed Professional
Spdv OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Zo
°9 I hereby affirm that I am exempt form the Contractors License Lew for the
cu3 LL y following mount.(Section 7031.5,Business and Internm Code:Any city mercury TEMP.METER OR POLE INST.
O which re t to construct,alter,improve, I p y s
Mea requiresh permit
fie airan moment POWER DEVICES
C=�� prior rn its issuance,also reyuircsthe applicant for such pemtit mlileaeigned statement
yI K O that he is licensed Possum,to the provisions of the Contmcmre License Law(Chapter
is. eLL 9(commencing with Section Will of Division 3 ofthe Business and Pmfeuions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefrom and Ne basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
AZT Section 7031.5 by any applicant for a permit subjects the applicant to a civil penaRyof � . �
2H
0 not mom than five hundred dollars($501)
1 . NEW RESIDENTIAL ELELTIt S Q.FT.
C p ❑ I,asowneroflbe properly.ormyemployeeswith wggesas theirsolecomperuation, Q STORKS TYPE CONSTRUCTION
y °.: will dotbe weak,unit the mucturc isnotimendedoruffcred for sale(Sec.7044,Businam
and professions Code:The Contractor's License Lew does not apply to an owner of
property who bui Ids or improves thereon,wit who dues such work hi meal f or through his
ownemployees,provideithat such improvements denotintendcloroffemd tarsale.If, OCC.GROUP RFS.UNITS
however,the building mintpmvcmem is std(]within one year of completion,the owner
builder builder wil I have Bre burden of proving that he did not build or improve for purpose of
.Jr.).
❑ I,as owner uftheproperty,am exclusivelycomracting with licensed commonest to QTY,. PLUMBING PERMIT 17EE FLOOD ZONE APN
onsmad the project(Sec.70,;a,Business and Professions Ced.0 The Cmunicmr'e
Licenu lsw does not apply loan ownerofpmperty,whobuildsorimprovesthereon,and PERMIT ISSUANCE
who contracts forsuch pmjeca with acormactor(e)licensed Portugal to the Contractor's ALTF,R-URA & 1
License Law. (' FEE SUMMARY
❑ 1 am exempt under Sec. B&P C far Nie reason BACK FLOW PR01' .DEW{CIL U9l IDL FLT:
TARY Y_N
Owner Date / �w RECEIPT st
WORKMAN COMPENSATION DECLARATION DRAINS-F100R,R FA�tF.A1CD�D li�+e F OLTAX YN
❑ Iherchy affirm Netlhaveo ccnifiwm of consenuo ulpinwre,orecertifiwle of FlNTURES P 'TRAP //''�� _d RECF,IPI'M -
Wodeas'Compensation lnsuranmaracenifiedcnpy Nercof(Sec.1800,Lab CJwhich eL
IPRK IEEt YN
rs all employee's under this perrniL RECEIPT'p
Policy# GAS-EA.SY .M 1 IN BUILDING DIVISION FF,F.S
Company 6lJB/✓ GAS-HA.SYSTEM-OVER4(EA) PLANCHECK FEE
�(�ified copy is hereby famished. ,
Certified copy is filed with the city inspection division. GREASE/INDUSTR,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be eomplead ifthepnmit is for one hundred dollars($100) SEWER.SANITARY-STORM EA.200FT. ENERGY ME
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/F,LECIR
not employ any person in any manner so as to become subject to Ne Workers' PAID
Z Compeamtmo LawsifCalifomia. Data - WATER SYSTEM/BEATING Dam Receiptp
O O Applicant
NOTICE TO APPLICANT:If,after making this CertiBcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT TOTAL:
to become subject to the Workers Compensation provisions of the Labor Code,you must
7 forthwith comply with such provisions or this permit sball W deemed revoked. BUILDING FEE .
I'f"I5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a,in smmtioa lending agency for the peHortnan a of
U O the worker which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE —v0
Lender's Name
0 F Leaden Address QTY. - MECIIANICAL PERMIT FEE PLUMBING FFEEV 1 cenily that 1 have read this application and suite that Ne above information is g'k.r e%* "
correct.l agree to comply with all my and county ordinances and sm¢laws relating to PERMIT ISSUANCE MECI IANICAL FEE
tibuilding construction.gad hereby nuNorize representatives of this city to enter upon the
abCONSTRUCTION TAX
V
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep harmless Ne City of Cupertino against
linbilities,judgments.cnsb end expenseswhichtmyinanywayaccmeagniestsis Ciry AIR HANDLING UNIT(TO 10.00 CFM)
in conseyuence of gran gofthispenna.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Appl C trectur pate EXHAUSTHOOD(W/DUC) PAID
ZARDOUS MATERIALS DISCLOSURE HEATING UNIT(1'0 100.000 BTU) Date Receipt at
Will the gpplicam or forms building occupant emoor handle himrdma material - /)
as defined bythe Cupertino Municipal Code,Chapter 9.12,and Ne lfeahh and Safety HEATING UNIT(OVER 100,000 R7'U) TOTAL: VV
Code,Scni 255J2(n)7
13 Yes 11 No
VENTILATION FAN(SINGLE RESID)
❑
Will the applicuntorfmurc building occupamuxequipmentardevices which<mit
BOILER-COMP(3HP OR 100,0011 BTU) ISSUANCE DATE
breardaoa air corearriumas as defined by the Buy Area Air Quality Management BOILER.COMP(OVER 100,000 BTU) pT p Pi S n
District?District? L� 2d
❑Yes C1No NEW RESIDENTIAL MECH. SQ.ET.
1 have read the Nostrums materials requircmenrs under Chapter 6.95 of the JUL 2 6 1994
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenanWhat it is my responsibility to notify the
cc
Occupancy.
of the myuircmenta which most M1e met prior m issnnncc of n Ccnificme of r
pnney. Cil Vr 'ur'uv erU
Ownermiathoriudagem Data TOTAL: ISSUED BY: ��+
OFFICE