26955 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO t.HLIHNG-FCFOTR PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n C 5JC
BUILDING DIVISION - - IIDILDINGPRO.IECTIIIEN'TIBICA•IION G
BUILDING ADDRFS SANITARYNO. AFPLICATIONSUBMITTALDATE
/ UNIT# I.O'Tis
0 Nit N E: t PITON . CONTRACT AM^ LICNO:
t N/C CONTROLp
ARCRI MCDENG27.1 i R: LIC NQ. A R fi 46 ,T&,� ❑
CONTACT: PHONE: sxr,.':21;a x5ak.'- I' ' 9UILDINO PERMITINFO
nVj,: v EL'ECyTRIC,PERMIT •E
'" 1a 'R�*'x - BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IOBDESCRIPTHON
GCZ I hereby affirmthat l am licensed underpmvisionsofaapmr9(commencingwith
POO
Section
II'Division Jof the Bmiandid l Professions Code,and my license is in PANELS
FK �G UPTO200AMPS
Z W License Ims a `c Lic,am
or 6y Dat Corector 201-IOW AMPS
ZOvs ARCIHICT'SDECLARATION OVER I000 AMPS SQ.FT.FLOOR AREA S/SQ.IT.
OZ_q I understand my plans shall be used a public records.
Hf'; SIGNS ELECTRICAL PAID
� Licensed Professional
a� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
A.F I hereby affirm that I em exempt from the Contractors License Law for the MAR 22 1995
t+-rn following hamon.(Section 1031.5,Bushmas and Professions Code:Any city or county TEMP.METER OR POLE INST.
C`� which requima a permit to construct,alter,improve,demolish,or repair any madam
s�Y2 prior to its issuance,also requires the applicant for such Permit to file a4grad statement POWER DEVICES
Op TLmheislicensedpureuunnnthepnwlsinnsoftheCom.......xLicense Low(Chapter IIY VruurekllNO
aao�' 9bnomcncing with Section 100B.(Division3ofthe Business and Profecomes Cole) SWIMMING POOL ELECTRIC LUATI
ort hat he is exempt themfmm and the basis ficumaalleged exemption.Any vi.ladonof OUTLETS-SWITCHES-FIXTURES
QSection 1031.5 by any applicant for a permit subjects the applicant o a civil penalty of
G not more thin five hundred dollars($50b. / il
m C1I,mownerufthepropeny,ormy employesswith wages as theirmlecompenciamn, NEW MSIDCNTIAL EhECTR _SQ.FII STORIES TYPECONS'TRUC'OON
a3— will dolhewmr,andthe suunure is not imendedorofibred for side(Sec.8144.Basinc
and Professions Code:The Contractor's License Law d«s not apply to an owner of
pottery who hui ldsor improves th emon.and who does such work himselfor Throughhis
own employees,provided that suchimpmvements a aradintendedoroffcred forsale.If, OCC.GROUP RES.UNITS
however•the mildingor improvement is sold within one yearofsmmpinion,the.wner-
he burden of that he did not build m int rove for f TOTAL:
builder will haveda,
pmvin8 p varp.a=.
veto). QTY . .. . -
❑ Los ownerofthepmpcny,ant exclusively contracting with licensed contractors nacm t QTY.(V #-Y t, PLUA1I31NG,PLRMIT + PEE FLOOD—ZONE nPN
construct the project(Sec.1014,Business and Professions Cole:)'Em Convector's
License Lawdoes not apply to anowncroTropeny who builds or improves thereon,and PERMIT ISSUANCE
whocontm.tsfor such projens with u contractor(s)licensed pursuant o the Contractor's n1:IFR-DNAIN&VINT-WA'TEIt(EA)
License Low. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDRFIEU
SANITARY Y N
Owner Dot= DRAINS.FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSA'T'ION DECLARATION SCHOOLI'AX YN_
1 hereby offimt that I have a cenificale of continuo se f-insure,or a cenifiwtu RECEIPT p
XTURFS-PER TRAP
%Compensation lmumntt.rucenifiedpy coHereof(Sec.3800,Lab CJ nth PARK TLE Y N
oversell e' this permit G A.SYSTEM-1 INC.4OITTLUS RDIVISION
P.Ilcy p BUILDING DIVISION FEES
0 5esa d unify is hby famished. GA -EA.SYSTEM OVER 4(EA) PLANCI HECK FEE
CmiGed copy is died with the city minivan.division. GREA'EINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM BEERS' GREAS TRAP SOILS FEE
COMPENSATION INSU E
(Thissectummadnalbeco it is for one hundred dollars 1$100) SEWER-S ITARY-STORM EA.2WFT. ENERGY IEE
or less.)
Icenifythatinthepe otmance ofthe work for which thio permitis sued,lshall WATERHIiAT WryIiNT/ELI3CIR ap
nm employ any Tarsen- any m ea 1.became subject's t Workers' pplp
Cnmpensmmu Laws.(Caifnno. Date s. WA' SYSTfi /TREATING Dam Receipt
O Z Applirmd
z 1) NOTICE TO APPLICANT IL after making thio Cetlificete of 'm,you shoot) E :SIDE IALPLMIL SQ.FT. TOTAL:
V] become suhjano the Work ra Compea.m.pmvisimi Cole,you mus
� ; forthwith comply with such revisions or this Permit shall edmvoked. / BUILDING FEE
O CONS RUQI'ION LB IN EN Y SEISMIC F13G
1 hereby affirm that the rs c.nswcd.n adi gan cy f f ti
the work for which this Derma is rssued(Se 3 v.C)
TOTAL: ELECTRIC IEE
C) Lenders Add lk TI' f $ y ss. PLUMBING HE O
ti
OH Isnd I vert
(. 7MECFPANICACPP,RMIT; lLC .
U 1 mngr etat 1 have send na application and ata het the above iw,red:Gan t
carted lagree to comply with Icily and county ordinances and mmelawa relay o PERMIT ISSUANCE MECHANICAL FET?
V) building construction•and hereb tmhorice represenmtivesofthis city lumber nthe
U z uhove-mentionedpropenyf.rins mirmparpnses. ALTER OR ADD TO MECH. CONSTRUCTION TA%
(We)agree to save,indemni and kap harmless the City of C.P111him against
liahilitia,judgarms,coatsandexpc seawhichmay inanywryac gamstsvd City AIR HANDLING UNIT('1'O 10.000CFM)
consegoe ecofthegra.tingefthi.permit.
AB HANDLING UNIT(OVER 10,000CIM)
Signature of ApplicanUContranor Dam EXHAUST FOOD(W/DUCI) PAID
IIA2.ARDOUS MATERIALS DISCLOSURE IMATING UNIT(TO 100,000 BTU) Date Receipt p — 'j/-'/
Willtheapplicant or future buiIdi goccupent Hors or hundlehaeardousmaterial IIGTINO UNIT(OVER 100,000 BTU) 'TOTAL: / /
ea defined by the Cupenin.Munn Code,Chapter 9.12,and the Health end Safety
Code,Section25532[a)
CI 'l
yes VENTILATION FAN(SINGLE RESID)
❑ No
BOILER-COMP(301'OR 1 W,fl(10 BTU) ISSUANCE.DATE
Will theapplicanl or future buildingoccupam umequipmenmrdevices whichemit /k
he amdous air contamina {� Ants m&SWed by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r
District? �.IG/ ,
CI yes NEW RESIDENTIAL MECH. SQ.PT. MAR 22 1995
I have read the heezrdm A
omaterials requirements under Chapter 6.95 of the
Cnlimorld Health&SafcI C e,Sec,una 25505,25533 and 25534. 1 understand that CII I �I �"I'Lf1IINO
if the building docs not torte ly hit .am,that it is my responsibility To notify the GUPE
N
occupant of e ' me a wh' u \tun prior 10 issuance of a Certificate of
O cup
Owner.math rind agent Date TOTAL: ISSUHI
OFFICE