16266 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO D DI s-ELh. RI A. , PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n C n �C
o
BUILDING DIVISION BUILDING PROJECI'IIJEN nF'ICATION LVG
BUILDING ADDRESS: TE
,I ' /1 SANITARY NO. AIPP,LICA9lON SDRMITTAI.DA
NeA, J �/�Cq UNIT# /-F LOT# �1 LM/
OWNER pMIi:� ;IIONB: ON'I'RACTO ;SNAMF,: All 86,3?O PO
1I�Pnn�rnnCC., ll 99 N/C CONTROLp
ARCIII I'CCI'/IiNGIN13IiR: LIC NO: _ ADDWJ sI US- VO�I C(Lc% "/&Y
CONTACT: !/ PHONE: / BUILDING PERMIT'INFO
QTY. ELECTRIC PERMIT FEE 1l4�U�Cc
yy I—G3I S PERMIT ISSUANCE PLU ELECT MEC i
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL , OB DESCRIPTION
QWz I herebyaffirn that l am licensed underpmvisionsofChpter9(commencing with gl�
.100 Sec0on 00000of Division 3ofshc Business and Professions Code.und my theme is in PANELS '
FFA-PI dull Lm<e naJ effe IIP TO iIp AMPS
Lic.#
m ate se C.mmctm 201-1000AMPS p1
DOZ va I understand my plansRshalll be used as publicNrecordc OVER 100 AMPS 1 B ( l'� ISWT,�y,00R qR $/SQ.IT.
2'Y SIGNS ELECTRICAL IL' I!F' 9}f �I)I u
Q` Licensed Professional t
ay�V OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
0,H 1 hereby affirm that 1 am escrupt from the Contractor's License Law for the
t+13ww following,coeur(Section703 L5,Business and Profession.Code:Anyciqu,rmnty TEMP.METER OR POLE INST. / JL4?1
.
"t¢ which inquires a permit m construct,alter,improve,demolish,or repair any swcturc { G
YJ7 priorm its Issuance,also requires the applicant for permit file a signed statement POWER DEVICES
M<0 that he is licensed pursunm to the provisimam me Cmumetor's License Law(Chapter
a Xo�' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALl1A'fj�
WM, or that he is cxcmpuberefmmand the basis fcadmidleged exemption.Anyvimatim.1' ��(�
�zQ Section 7031.5 by any applicant for a permit subjects the applicant to n civil penalty of OUTLIiTS-SWITCHES-FIXTURES ' oO�
SC not morethan five hndred dollars($500). NEW RESIDFNITAL ELECiTt —SQ.FT.
N f—o EI1,asowneroftheprop ay.ormyemployeeswithwagesastheirsolecompensadon, STORIES TYPF.CONS9RUC ION
y3r_2 M11,4,he work,and 11m....comm is not imadedoroffcnel firma,(Site7044,Humus,
and Professions Cade:The Contractor's License Law does not apply to an owner of
progeny who builds.,improves thereon,and who does such work himself.,through his
anployeex.provitleJ that arch impmvememsarenm imendednnfffered Bnsale.If, OCC.GROUP RES.UNITS
however,the building orimproveme d is sold within one yearafcompledon,fl cow ter- ,A
builder will have the burden of proving that he did not build or improve for purpose of
sale.),
❑ I,as ownerof the properly.amexclusivelyconuaning with licensed c.ntmemrsm QTY. "PLUMBING PERMIT FIE. FLOODZONE MIN
..tinct the project(Sec.7,P1,Business and Professions Code:)The Contmctor.
Licenvel.awdocsnm apply to nnnwnendproperly wh.builJ.a nrimprnvesthercnn,anA PERMITISSUANCE
whocantmc%fur such Projects with a commetods)IicensW personal to the Commetor's
License law. ALTHR-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under See. ,B&PC for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dae RECEIPT'#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCIIOOL TAX YN_
❑ Iherehy affrtm thutlhaveucenificmc of cones..selGinsum.oracenifcem ofRECCIP1'#
Workers'Commt
penion loneranceoa
rceniBedt.,dareof(See.3800.1-mC.)which , IIXTURI3-PER TRAP PARK FEE Y N
coven all employee's under this permitGAS-EA.SYS'TF.M-1 INC.4 OUTLETS RECEIPT#
Policy p BUILDING DI VISION FEES
Company GAS-PA.SYSTEM-OVER 4 RAI PLANCHCCK FEF.
CICertifredc.,kheabyfamkled.
❑ Cenife copy is Bled with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADI
CF.RTHeICATF.OF EXEMPTION MOM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectlonnee not be complete ifma permit is for one hundred do]Wa($100) SEWER-SANITARY-STORM ISA.200FT. ENERGY FBI!
or leer.)
I cemythat in the perfmaniu a of the work for which this permit is issued,l shall WAT17R I IEATI;R W/V ENT/ELECTR
not employ any person in my manner so as to become subject to the Workers' PAID
ZCompensation Laws of Califomia. Date WATER SYSTF.M)TRPATING Data Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
A] become subject o the Worker's Compensation provisions of the Labor Cade,you must
afonhwilh comply with such provisions or this permit shall be deemed revoked, BUILDING 17EE �y
w z CONSTRUCTION LENDING AGENCY SEISMIC IEE b
rrCJJ I hereby affirm that there is a construction lending agency for the performance of
u mit 0 the work for which this Peris isei(Sec.3097,Civ.C.) ELECTRIC FEE
Lendeea Name
F Lender's Addraa QTY. �;�„ _ MECHANICAL PERMIT' ,FEE: PLUMBING FEE
C1 I certify that I have read this upplication and state that the above information is
correct. I agree to comply with all city and county ondircures and state laws reform$to PERMIT ISSUANCE MECHANICAL FEE
above
bomentioned
property
her indene ion pure resamtives.f this city to enter upon the CONSTRUCTION TAX
V z abov(We)sand pmpeny for inspection keep ho. ALTER OR ADD TO MCCH.
(We)agree to save,indemnify and keep harness the City of Cupertino against
liahilitics,j rants.costs and expenses which may In any ways .against mid City AIR IIANDLINO UNIT(IO 10,00 CPM)
in con a if the gm ing of this pe
// !1y' AIR IIANDLING UNIT(OVER 10,"C
FM)
Signor reof Applicant/Contractor Dam / EXHAUST HOOD(W/DUCT)
rnlD
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ig1,t100 BTU) Date Receipt#
Wi1I the applicant or future huilding.venpam stare or handle hamrdmis material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,01X)BTU) TOTAL:
Cale,Section 25532(x11 VENTILATION FAN(SINGLE RESID)
❑Yes 11 No
ISSUANCE DATE
Will the upplicamnrfmurubuilding occupant uses9uipmarordovioeswhiehemt BOILER-COMP(3HPOft 00, p BTU)
hamrdous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER CI yes
BTU) Pf p
District? P PY
Yes ❑No NEW RESIDENTIAL MCCH. SQ,FT.
I have rad the hrardous materials requirements under Chapter 6.95 of the 'APR 12 1994
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building docs not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must M met prior to issuance of a Certificate of
Decaparcy. ITYY�/yu.t-UUUe.
Oams"mauderieed agent Date ISSUED BY. VJY�tII
OFFICE