26572 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ✓
CITY�P CUPERTINO taILUG-ELECTRICAL. PERMITNO,
BUILDING DFVISION APPLICATION/PERMIT PLUM BI.NG-MF.CIIANICAL 26572
BUILDING PROJRCI'IIIEN'UFIC"ATION
BUILDING
1R.SS'. � CONTRACTORS
G AD✓�DSANITARY NO. APPLICATION SUBMITTAL DATE
0 Owow
#- I'DME: LOT#
OWNERS NAME: PHONE:
c NSC CONTROL p
•ARCHITECT/ENGINE
F;R: LIC NO: ADDRESS `l
T7 QALA N7W IA /""C. P,oLo
CONTACT. QTY. ELECTRIC PERMIT FEP"
IS3HONE BUILDING PERMIT INFO
✓GI+Sn'.' l/�1
s.nA��kS��--�� --s BLDG ELECT` PLUMB MACH
LID ni-'� S 1� 017/� PERMIT ISSUANCE fYyJ` IL��� 19 kf'L�7
LICENSED CONTRACTOR'S DECLARATION APPLIA S-RISIDEMI'IAL JOB DESCRIPTION
CZ Ihereby affirm shat l am licensed under pmvismnxof ChVter9(commencingwitM1
OU fullforer and Section effecof t.
n3 of the Business�l'rofessirre Clyde,and my license ism p ELS
62,4 License Clm Li<.p_'' UP T02 AMPS IL�IVIw
P.Z< Dae Crmrucmr tt 201-1000 AMPS
F HZ, AR IIITELTS DECLARATION SQ.Ff.FLOOR AREA E/SQ.FT.
CON_ OVER 1000 AMPS ( 32->. 60 00,— 1 understand my plans shall be used as public rmaNa.
SIGN.I
E.
gg < Licensed Professional OWNERBUILDERDECLARATION S ECI LLCC UIT/MIS
BOy I hereby vffnm that I ma exempt from the Contractors License Law nr the
1a�30 fallowingreason,(Section 7031.5,Business and Profusions Cade:Any city., P TER RPOLE INST.
f3O¢ which requires a Permit m cnnswCt.after,improve,demolish,or repair any swcturc
Kn�7 priorm its issuance,also requires the applicant for such Permit o the a signed statement POWERDEVICES
ty 60 that he is licensed putauum to the provisions of the Contractors License Law(Chapter
a p�' 9(crmmencing with Section 7ML of Division 3 of the Business and Professional Code) IM MING POOL ELECTRIC VALUATION
,may or that he is exempt therefrom and the It for the alleged exemption.Any violation ofI2b /]�
J+ Sedion 7031.5 by any applicant for a permit subjects the applicant a civil penalty of OUTL -SWITCiIFS-FI RES Y!� "I
not more than five hundred dollars(8500). NEW RESID ALE . _SQ.Ff. -3 STORIES 'TYPE CONSTRUCTION
a' n❑ Le awn five
Bred ry,or ($500)loYeeswithwogesas theirsalecompensation,
p- will do the workload the structure isnot intended reoffered batiste(See 7044,Business
and Professions Code:The Contractor's License Law fres not apply m an owner of
property whabuilds orimproves thereon,andwhodres such wart himselforthough his OCC.GROUP RES.UNITS
own employees,provided that such improvements are not intended m offered fur sole.If,
however,the building or improvement is sold within me yearn(completion,theowner- TOTAL:
builder will have the burden of posing that he did not build or improve for purpose of
le.).
❑ I,mownerofthepropeny,ameaclusivelycrntraatingwithlicensedcontractomto QTY. PLUMBING PERMIT FEE FLOOD ZONE ANN
atatraa the project(Sec.7(14,1,Business and Professions Code:)The Contractors
License lawdoes not apply in an ownerofproprny whobuildsrrimprovesthereon,and PERMIT ISSUANCE
who contracts for such projects with a comractm(s)licensecipunatiamthe Contractors
License Low. Af T13R-DRAIN&VENT-WATFA(EA) FEE SUMMARY
❑ I am exempt under See. ,B&P C for this Lesson FEE
BACK FLOW PROTECT.DEVICE T. E
SANITARY Y N
Owner Date RECBIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby
,m...that lhave aceni0cateofcansem toself-insure,nrncenificate of FIXTURES-PER TRAP RECEIPT'#
Wrers.1 ComMnsetio ad,
paruccnifed copy thereof(ga.380o,Lab CJ which PARK PEE Y—N
—
covers all employee's under this prnnit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
policy# BUILDING DIVISION EFS
❑ComCertified copy is hereby famished.ny GAS-EA.SYSTEM-OVER 4(HA) PLANCHECK EE
❑ Candied copy is filed with the city inspection division. GREASEIINDUSTRI.WASTE INTERCEPTOR GRADING IEE y
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sce6mrseed oat be completed ifthe pereit is farone hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE ZA Z
or less)
I certify thin in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELH=
not employ any person in any manner so as to become subject to the Walken' PAID
Compensation Luwerf Califomia. Dam WATER SYSTENUTREATING Dute Receipt#
Q z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,T'r. O L:
F ) became subject to the Workers Compensation provisiomrftbe Labor Code.you most BUILDING LAE -s
a - forthwith comply with such provisions or this permit shall be deemed revoked. p
CONSTRUCTION LENDING AGENCY MISMICFE'
1 hereby affirm that hem is a construction lending agency for the performance of
U O the work far which this pcmlit is issued(See3097,Ci,C.) TOTAL: I'41 .33 ELE01ME I 3
Lender's Name
Lender's Address Q'I'Y. MECHANICAL PFiRMIT FEE PLUM E
I certify that 1 have read this application and state that the above information is MECHANIC FEE
�"' D7 correct.I agree m comply with all city and county ordinances and$rate laws relating to PERMIT ISSUANCE �f
"
� buildingmustructirn.and hereby stalactite repusennatives ofthiscity to enter upon the CONSTRU TION TAX
1..) Z above-mentioned propmy for inspection puryrsu. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and keep formless the City of Cupertino against
liabilities,judgments,costs and expemes which may in any way accrue against said City AI R HANDLING UNIT 07010.00(1 CFM)
in< encs of the granting of this yam t.
AIR HANDLING UNIT(OVER IO,000 CFM)
SirioureofApplicanuCinamican6l
Dae EXHAUST HOOD(W/DUGT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10100.1X11)BTU) Dam Receiptp
Will the applicant or future building occupant store or handle hazardous material I(EATING UNIT(OVER BROW BTU) TOTAL:
u defined by the Cu,symao Municipal Code,Chapter 9.12,and the Hea th and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HPOR 100,(100 BTU) I68PU{>, ETE
Will the applicantorfuturebuilding occupontusemuiormntordevices whichemit led 9a u&I
• hazallous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00s1 BTU)
District? ❑Yes ❑No NF"W RESIDENTIAL MECH. SQ.Ff. NOV 23 1994
I have read the hazvdous materials requirements under Chapter 695 of the n'•py
California Health&Safety Code,Sections 25505,25533 and 25534, l understand that V 11 V� �Ur'Cft111Vt
if the building does not currently have a tenant,that it is my responsibility to notify the �1j^Yy�AI
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: 1'7)�,3 ISSUED BY:
OFFICE