25002APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING- ELECTRICAL I PERMI'TNO.
WAPPLICATION/PERMIT
PLUMB puNteG - MECHANICALMECHANICAL25002
BUILDING DIVISION unn.usnr. votacutty Itxr•.n
t nTvTON
20330
M
2S> 9730
m4izi4 nc4ir, /?oo $e2 -7728V
LICENSED CONTRACTOR'S DECLARATION
1 hereby afrrm Ihm I nm licensed underpmvisions arChapter9 (commencing with
Section 7") of Division 3 of the Business and Professions Code, and my license is in
full fors and effect.
License Class Lia#
Date Conn..
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
Licensed Professmoul
OWNBR-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following notate. (Section 7031.5, Business and Professions Code: Any citym comity
which inquires a former to constmect, alter, improve, demolish, or repair any anucture
prior to in issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 91100) of Division 3 of the Business and Professions Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 70.1.5 by troy hill it for a pcmtis nvbjems the applicant to .civil penalty of
nm mom than five hundred dollars ($500f
❑ I, as ownerofthe property, army employees with wages as theirsule compensation,
will do the work, and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Conusever's License law does not apply to an owner of
propertywhohuilds or improves themon,and whodoes such work himselforduough his
own employees, provided that such improvements are am imended ormlered fnrsale. If,
h.wcvec,,hc building or improvement is sold withinone yearofemoplerim,the owner -
builder will have the burden of proving that he did not build or improve for purpose of
side.).
❑ I, ss owner of the property, am earl usively contracting with licensed contractors to
construct the project (Sec. 70,14, Business and professions Code:) The Contractor's
License Law does not apply to an owner ofpsVerty, who builds orimproves lhercon,and
whocontmcts branch projects with a contractors) licensed pursuam tothe Contractoh
License Law.
❑ I an exempt under Sec. , B & P C for this reason
Owner Data
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm that l have acenificateofewasent to ul4insurc. orusnificate of
Workers' Compensation Insurance or u cenlfied copy thereof (See. 3800. Lid, C.) which
cars. all employee's under this permit.
Policy #
Cmnpany
❑ Centuries] copy is hereby famished.
❑ Centrist copy is riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('This socdon need not he complied RNe permh Is krone hundred dollars ($100)
or less.)
1 cenify the, in the performance of Ne work for which this permit is issued, l shall
not employ any person in any manner so as to become subject or the Workers'
z Comrensmionlawsof Califomia. Date
Applicata
z NO VICE TO APPLICANT: IL after mining this Cerificateof Exemption, youslmuld
HV1 become subject to the Workers Compensation previsions of the Labor Code, you must
5 forthwith comply with such provisions or this remain shall be deemed revoked.
yW Q CONSTRUCTION LENDING AGENCY
� z I hereby affirm that then is a construction lending agency for Performance of
U C) Ne work for which this Permit is issued(Sce. 3097, Civ. C.)
OL_t
r�a Lenders Name
lender's Address
U 1 notify that I have read this application and state thin the above information is
correct. I agree to comply withal) city and county ordinances and state laws relining to
f~ V) bei lding construction. and hereby authorize repmsernatives of this city to enter upon the
UZ above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap harmless the City of Cupenim against
immiinies,jud memx,msls end expenses which may m myw.yuccour against said City
\
in
conuquofihegranringohispermil.
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous mmerial
us defined by the Capita., Municipal Code, Chapter 9.12, and Ne Health and Safety
Code. Section 25532(x)7
❑ Yes ❑ No
Will the appliennt orfumrebuildingoompunl ukkxrmpmentordeviceswhich emir
hazardous air contaminants as dermad by the Bay Area Air Quality Management
�istricn?
❑ Yes ❑ No
I have mud Ore harridans materials reyairencon under Chapter 6.95 of she
California I health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requiremems which must be mel prior to issuance of a Croup care of
Occupancy.
Owner or authorized agent Dole
bb:
Goo
ELECTRIC PERMIT
2? -6t3
PERMIT ISSUANCE
r ,Q
APPLIANCES -RESIDE
PANELS
UPT020OA4
I D
TEMP. METEI+1OrOLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTf.cTS - S ITCH - [1t
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROUP, AREA. GOND.
FIXTURES - PER TRAP
GAS - IA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (BA)
GREASE/INDUSTRL WAST[: INTERCEPTOR
GREASE MAP
SEWER - SANITARY - STORM EA. 2001cf,
WATER HEATER W/VF.NT/ELECfR
WATER SYSTE1,17REATING
NEW RESIDEN'I'JAL PLMB. SQ. IT.
TOTAL:
,MECHANICAL PIiRMIT'
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT(TO UI.V OCFM)
AIR HANDLING UNIT (OVER I0,000 CFM)
IIHAUST HOOD (W/DUCD
BEATING UNIT (TO 100,000 RTU)
I[EATING UNIT (OVER I00,003 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (311P OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. Fr.
X 000 50 "
STORIES PE
CC. GROUP
FEE LOUD ZONE
FEE SUMMARY
T 1, FE S
SANITARY Y D
RECEIPT p
SCHOOLTAX Y h
RECEIPT
PARK F17E Y b
RECEIPT a
BUILDING DIVISION FE
PLANCHECK FEE
GRADING FEE
SOILS FEF.
ENEROY FEE
PAID
Date cipr #
TOTAL:
BUILDINEE
SEISM FEE
ELECTRIC FET?
FEC PLUMBING FM
MECI3ANICAL F
GONS'I'RUCTIOI TAX
PAID
JUN 0l 1993
OILY Uf- i"U"CHIINU
ISSUED BY: 3
2? -6t3
r ,Q
NIC
❑
/CONTROL at
C ��
iXs�ie
FEE
BUILDING PERMIT INFO
DLDG
15
ELECT
❑
PLUMB MECH
❑ ❑
X 000 50 "
STORIES PE
CC. GROUP
FEE LOUD ZONE
FEE SUMMARY
T 1, FE S
SANITARY Y D
RECEIPT p
SCHOOLTAX Y h
RECEIPT
PARK F17E Y b
RECEIPT a
BUILDING DIVISION FE
PLANCHECK FEE
GRADING FEE
SOILS FEF.
ENEROY FEE
PAID
Date cipr #
TOTAL:
BUILDINEE
SEISM FEE
ELECTRIC FET?
FEC PLUMBING FM
MECI3ANICAL F
GONS'I'RUCTIOI TAX
PAID
JUN 0l 1993
OILY Uf- i"U"CHIINU
ISSUED BY: 3