26805 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I'll" vf:-:ErK PFRMII No. /y�� ^r5
APPLICATION/PERMIT 1'LUMIIING-M111fIANICAL {J H O V
BUILDING DIVISION BIIII.. G PROJECTIDRNTIFICA'1']ON
BUINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE;
.22A� 4aw e gr e/u/IT
ON]"fall LOTH
NERS NAME: PHONE: C TRACTOR'S NAMII: LIC NO:
\RClln-Cf/ENGINIHiR: LIC NNIC
O ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE
LICENSI?D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
a y.2 I hereby affirm that l am licensed underprovismimmC'hapter9(commencingwiN LOB DGSCRIPr10N
ise Semion]Bmlef Divisian3ofthe Business and Professions Cade,and my]irenx is in PANELS
KU� Licensefull lasseflcct. 1`/-/'�lr1w`Xu�[\✓ v{W'•••�
6241
License Class Lic.p UP T0200 AMPS
rFitQdDam Cotinactor 201.1000 AMPS
FyZ ARCf{ITF,CTS OLCLARATION SQ.IT.FLWR AREA S/SQ.FT.
ZOm" I mckirvnd my plans shotll be used as public nwourd. OVER 1000 AMPS
prut t O SIGNS ELECTRICAL
Q ,..I Licensed Prolcasinnul
1�CQ OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC.
kOyU l Imreby xfl inn that I ton exempt from
thethe Contacm Cache License Law for the
fellavFLLLLOm whichiequirena(Secti to)conl.Sci,alte.imp P,dermli .orrepycity or county TEMP.MFTF.R OR POLE INST.
wM1ICM1 requires x Ixmrit in consvun,setter,impnrva,demolish,ar repair any structure
EYE prior to its issuance,alxn requires the applicant for such permit to file a signed statement POWER DEVICES
�p that he is licemed pursmm to the p a,hiens ofine Conmacmr'a License Law(Chapter f1�I
SWIMMING POOL ELECTRIC 1
66�m 9(connnencing with Section 7")of Division Sof the Business and Profusions Code) If
BVyp.I„TI
,2,,, or that he is exempt thcrcfmm and the basis for the alleged exemption.Any violation of Ill I' L d9 II\VA
p.ZQ Section 703 LS by any applicant for a permit subjects the applicant a civil penalty of OUTLET'S-SWITCHES-FIXTURES -
than five hundred dollms(S500). NEW RESIDENTIAL ELECfA ISQ. ( -14�%i � n
BB. I,asuwnerofthepropeny,ormyemp]oymswiNwagcsatheirsolecompcnsadon. � I IST RI IV PE CONSTRUCTION
.
11 work,and the strucmmisnot imm�dcd proffered for sale(Sec.]D14,Business
and Professions Code:The Contractor's License Lew does not apply to an owner of IZ
Irrupt whobuildsofimprovicethcmun,andwhodms such work himxlforthrough his A I t
employ«a,pmviJW that such improvcmorsasnot insndedoroffesd fmsale.IL RES.UNITS
however,the buiidingor impmvement is sold within one yearofcompleuon,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve fm pulpox of
sal`)' QTY. PLUMBING PERMIT FEE FLOOD ZONE: APSE
❑ Luowncrnfthc pmpeny,umeadusivelycommning with li<eaxdconmmtorsto
consumer the project(Sec.7614,Business and Professions Cade:)The Contractor'sPERMIT ISSUANCE
License Law d«snot apply manownerofpropeny whobuildsor improves thereon and
who contrae¢foraveh pmjmts with acommmor(s)licensed pursuant to the Commctora ALTER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Scc. .B&P C for Nis reason BACK FLOW PROTF,Cf.OF.VICE TSIDF E..
SANITARY Y
Owner Date RF.CEIPTp
+c�a DRAINS-FLOOR.ROOF,ARTA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihereby xffinn thmlhaveacenificam of conxnnoself-insure,oraeerrificas of Fl%TURES-PER TRAP RECFIPI'p
Waken.'Cnm,amudon lnnuramem.cenifieJenpy thereof(Sce.3800.Lab C.)which PARK FEE Y N
re a 11 emploces under this k RECHIPI'p
Y ' pc^n' GAS-IiA.SYST IiM-I INC.40UTLF.TS BUILDING DIVISION PEES
Policy M
Company GAS-EA.SYSTHM-O V HR 4(VA) PLANCIMCK FIiIi
❑ Certifed copy is hereby fumished,
❑ Cenilicd copy is filed with the city inspection division. GREASIy1NDIJSTRL WASTE INTFRCFPTOR GRADING FEF
CHR'I'IFlCATF OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURPNCE
(This motion need net he completed ifthe Permit furore hundred dollars(5100) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
m toe.)
I certify that in the perfonnunceof Nework for which this permit is issued.T shall WATER IIIATHR W/VENT/ELF,CTR
not employ any person In any manner so u to become subject to the Workers PAID
Compenaauoa Lewsof Celifomia. Date WATER SYSTEMaRGTING Done Receipt
Q Z Applicant
zC) NOTICE TO APPLICANT:If.after making this Cenificasof Ezemplioo,you shouldNEW RFSIDFMIAL PLMB. SQ.FT. TOTAL:
ec
F^ y bomeaubjeet m Ne Wrfkcr's Compensation pm ¢
visimrfthe l<bor Code,you must
> foMwith comply with such previsions m this permit shall be domed revoked. BUILDING FEE
UJ ` SEISMIC FEE
G. Q CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the perfommnce of
U O T ELECTRIC FEE
the work for which this pcmrit is issued(Sec.309],Civ.C.)
tenders Name PLUMtlING FEE
0O F lenders Addmsa QTY. MECHANICAL PERMIT FEE
U I renify that I have read this application and stale that the above information is MECHANICAL.Fr.F.
7" DJ coned.I agse to comply withal]city and county ordinances and matte laws slating to PERMIT ISSUANCE
I-' ct.. building construction,and hereby uuNmim mpleaentatives mthis city toemer upon the
CONSTRUCTION TAX
U z mawe-mentioned prepcny for inspcmion Proponent, ALTER OR ADD TO MI CH.
(Wc)agree to save,indemnify and keep harmless the City of Cupenito against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I0,D00 CFM)
in ccnxyucnre f In=murng o'his pcoorm,
AIR HANDLING UNIT(OVER 10.(00 CFM)
'ignuwrc ol'Applicun nmraonr D c E%HAUS HOOD(W/DUCT)
PAID
IIA%ARDO1JS MATERIALS DISCLOSURE IWAI'INGUNIT('rO 100,0006TU) Dam Rot a
Will the applicant ar future building occupant store or handle haemdoua material
as Jehned bylhe Cali Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I(F(W BT U) TA
Cale,Section 25532(x)'! NU ILAl'ION FAN(SINGLE RESID) �,
1:1 Yes 1:1 No 195
FISSa,UUAaN5F.DA'm
W 1 theepplica Ifummbui]dingmcupaniusecquipmemBOILER-COMP(3HP OR I00,(0U BTU)ordeviceswhichemit 6/
�ha(uNou9 air comaminants u deftness by the Bay Ama Air Quality Managemem BOILER-COMP(OVI;R 1XI"BTU)
DiatriclR JUL 28 199
❑Yes ❑No NCW RfSIDIiM'IAI.MECII. SQ.FT. 4
1 have read the haamdous ma trials requimmems under Chapter 6.95 of the tar
California Health&Safety Code Sections 25505,25533 and 25534. l undersmnd that Lut tri I livu
ifthebuildingdocsnmcunemlyich asober,et itis myresponsibilityenotify the
Occupmt of the rryuisnxms which must be and prim to issuance of a Certificate of
OccuparxY. ,\ r\\�
Owner m authatired agent Date TOTAL: ISSUED BY: