26846 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING —KLEC'I RI AL PERMiTNO.
CITY OF CUPF,SIO NO APPLICATION/PERMIT PLUMBING-NIECHAN"
BUILDING DIVISION renrr ra — gen...........—.T..... n e n A O
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QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELF, PLUM❑B MECIT
El ❑
PERMIT ISSUANCE ��
LICENSED CONTRACTORS DECLARATION
l hereby, affirmthat l am litensedunde Imiskionsof(Tepter9(rommencing with
Second 70l Division Sof me Businessnnd professions Code. and my llceme is in
full force and effect.` I V
LicenxC l.icp 6 Z-1 1�
Dam Commcmr
A CHITECPS DEC ARAT N
I understand my plumshall beused as Public tecmds.
APPLIANCES
APPLIANCES -RESIDENTIAL
PANELS
' UP T0200 AMPS
JOB DISC ITT ']ON
U
281 - I AMPS r
[---AMP
OVER n00 AMPS I /�
OOR
m tE
^ ..s>•.
h_J V YF•li�
1YP 7
-
SIGNS ELECTRICAL ,
Licensed Professional
OWNER -BUILDER DEC ConaduON
ng ebymas affirmn.(Se mat 1 am exempt fdsm the Cosiones ro License law for the
following mamn(Section]B31.5, Business and Profeasiom Cade: Any city or countyTEMP.MEfGR
which requires a pennit it) construct, alter, improve, demolish, or repair any swcturt
prior to its issuance, also inquires the applicant for such perming file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter
9(commencing with Section 7")nf Division 3 ofthe Business and Professions Code)
deaempuoo civiny l of
therefmmntdme basis fmmects the
Section 7031.5
not m 'ban iv anyapplicantfora permit subjcctsthe applicanuoacivil penalty of
not mom than five hundred dollars (SSW).
ID1,mowneretmCPmpcny,ormyemployeeswiNwagesastheirsolecompensadon,
will do the work, and the structure isnot intended oroffcred lots ale(Sec.](JeW Business
and Professions Code: The Cnnvacmes License Law does not apply to an owner of
SPECIAL CIRCUIT/MISC.
OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTft _SQ. FT.
STORMS TYPE CONSTRUCTION
( 50 ANP CLCC.0 1 T —[aA G
property who builds nr improves memon, entl who Dues such work himxl(or ttwugh his
employees, provided that ach improvements are not intcndcderroffered forsale. If,
however, the buildingm improvement is sold withinone yearofcomple ion, the owner-
budder will have the burden of liming that he did not build or improve for purpose of
sale.).
OCC. GROUP RES. UNITS
'IOTA
C3I,asuwmrofinepmpeny.mexclusiveLycono-atingwimlicensedcmn to to
nnsmrd the pmjee (Sec. 70114, Business and Rofessions Crde:) The Comms or's
QTYPLUMBING PERMIT FEE
FLOOD ZONE APN
License lawdoes notanly 10 an ownerofpepeny, whobuildsorimpmves thereon, and
PERMIT ISSUANCE
wbncommns fmr.mch Projects with. convae0r(.) licensed pumand meennewo,
License Law.
❑ 1 am eacmpt under Sce. B & P C for chis reason
ALI17R - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
Owner
SANITARY YN
Dao
WORKMAN COMPENSATION UeCLARA'TION
❑ Iherobyaf6rtion Insuranceor i0cateofcopyther set ger. re,0r Lab C.)c which
fieri copy merenf(Sec.3gW, Lab C.)which
Workers' employeeSorer this permit.
all emDloyee's under this permit.
Policy
Policy n
DRAINS- FLOOR, ROOF. AREA, COND.
RECEIPT#
SCHOOLTAX Y N
RECEII'1'#
FIXTURES - PER TRAPcove
PARK FEE Y —N -
RECEIPT N
GAS - FA. SYSTEM-] INC. 4 OUTLETS
Company
GAS - EA. SYSTEM -OVER 4(EA)
BUILDING DIVISION FEES
❑ Cenified copy is hereby famished
❑ Cenified ropy is fled with the city inspection division.
PLANCHECK FEF.
GREASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRFASETRAP
SOILS IEE
This wetion'iced not be completed ifthe Peron is for one hundred dollars(SIW)
orless.)
SEWER - SANITARY - STORM EA. 2WF7L
ENERGY FEF.
Q O
I certify that in the perfnrmence.fthe weak for which 'his p—it is issued, I shall
m employ t any goner so as to b me ject��e_ Workers'
nompenI yl ati( q�D'ute T
Applicant luso /O4
WATER HEATER W/VENT/ELEGIR
PAID
Date Receipt if
WATER SYSTEM/fRIiA9'ING
z
2
Fonrect.
U Z
NOTICE T LICANT: If, afir—,.a ng this Centficamof Exemptien,y.. shouldMRUIDEWIALP�SQ.
become subject to the Workers Compensation provisions ofthe Labor Code, you mast
forthwith comply with such provisions or this permit shut[ be decided revoked.�
CONSTRUCTION LENDING AGENCYSEISMIC
1 hereby affinm that there is aGnawtinlening agency for the performnce ofL.1
the work for which thisp.itc.3W], Civ. C.)TOTAL:
Name—AA AOLenders Address
t certify that I M1avc read this application and statemat the strove information is
[agree to comply with all city and county oNimmces and stain laws rotatintoMF,CIIANICAI.
building construction. and hereby amhodze representatives ofins city to enreraped the
abate-mcntimned pmpcny far inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Canadian against
liabiliti ends, costcand eapenxswhich may in .1 way acerae against said City
in canucyuc dicgrantingof permit.
/ „ e_9-9¢
FT.
TOTAL:
9UILDING Ig3E
FEE
ELF:CfR1C FET:Lender's
T FEE
PLUMBING FEE
FEG
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT TO 10,Wn CFM)
AIR HANDLING UNIT (OVER 10.0110 CFM)
Stgnamre of Apple-1/11numna r Data
EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
Wilttheappllcamm failure building occupant.wore mhandle bromem us mated.]
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Gide, Second 25532(a)F
❑ Yes Va No
/S
PAID
Dme ReceiptN
HEATING UNIT (TO IW," BTU)
HEATING UNIT(OVER 100.000 BTU)
T T
VENTILATION FAN (SINGLE RESID)
Will the applicant mfu[urr: builJingoccupant uxequipmemordevittswhich emit
M1umdous tit conammunts as defined by the Bay Arta Air Quality Managemcm
District,
❑Yes 5Nn
BOILER- COMP OR IWpW BTU)
BOILER- COMP IW,WO BTU)
pI �U �NBC��E'DATE
RR (�
AUG _" 1994
NEWRESIDEWTIALMECIF SQ.IT.
read the Infamous mammals requirements under Chapter &95 of me
Health Code, Sections 25505.25533 and 25534. 1 undernandmat
gds t=-dy have a tenant, that it is my responsibility to notify the
the rpy ms � i h t be met prior to issuance of n Cenifiam of
/ °
L
CITY Ur IA.(
urtlil
..maorr'trcd ab."'r '"" ✓`T"'� Date
BY: -'
TOTAL: ISSUED