27263 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBIDING-ECECrRE"I PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. O
BUILDING DIVISION BUILDING PROJE.CIADENFIFICATION J
BUILDING ADDRESS: _ 1 /y�,. �► f./.I��� SANITARY NO, APPLICATIONSUBMITTALDATE
17�61 �uNI��M'/pl w FAV LOT# Ll���—l�
TS NA MC:�� O1- - PHONE: CPN ACTOR'S E: s LICNO: NIC i-cklCONI 1.e
AI I[^•��`• LIC NO: DRESS: - ❑
CONT'AM PHONE: ',s.n$ 4 fiY.B kfiiy? +;;
EI,CCTRIGPERMITtr' a; FEE BUILDING PERMIT INFO
^)' ,*Ttx ` V •K''- BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ 'Ej E ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyrz I herebyaffirm that lam fmmxvd.ndenprovi,mm.fChrpmr9(commendmilwiN JOB DESCRIPTION
POO Section 7")of Division31 oftbe Businessand Professions Code,and my license is in PANELS
yg fall force
se Claccffen. Lm is UPTO200AMPS
GG Data Class Contractor
i-6o, Data G.CT'S D 201-1000 AMPS
Z 0 z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
CZ 1 understand my phone shall be used es public records.
C�F w SIGNS ELECTRICAL
hggx J Licemed Professional
< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
kO a V I hereby affirm that 1 am exempt from the Contractor's License Law for the
613 LL i following reason.(Section 1031.5,Business add Professions Code:Any city or county TEMP.METER OR POLE INST.(:�i which requires a permit to construct,alter,improve,demolish,m repair any structure
m its issuance,aho shed licint for..ch uo file.signedsntement POWER DEVICES
prior matures pp pcmd
y1�p0 9(cheisncing with Smmmthepnwisioneof the Ce Business
License Law(Chapter
ddpK Y(commencing SWIMMING POOL ELECTRIC
( gwith Section Division Sof theed exemption.
vote Code) VALUAJ'ION
� or that h7031.5 by anys exempt applicant for
the basian sbjetsthedeeemant to civil
of OUTLETS-SWITCHES-FIXTURES
F Z Q no,more
than
five
hu dred doll rs($50 mit subjects the applicant to civil penalty of
ATO
no,mare than Eve hundred dollars(g5110). _ NEWRESIDEIMALELECR S .FI'.
aC m ❑ Las uwrk,anhepropeny,ermyempindedorofered forsidei(Ser.compensation, —SQ,FT. TYPECONSTRUCTION
3— will Jmhework,.ndthe structuremnt intendedorLaw offeredfor
not apply
to an Business
and Professions Cale:The Cost ercon, nw who
Law does not apply to rt owner of
propoweenywho yces,pdsonimprovesch improve emand,nsuchworkhimseffor fidecihrough his
employees,proviJetl that such improvememsere not imrndedmoffered(orsaie.If. OCC.GROUP RES.UNI'I:S
lu Wever,the buildingor improvement is sold within one year of completion,the owner,
builderwit[have rhe burden of proving that he did not build at improve for purpose of TOTAL"
nada) PLUMBING PERMIT ,FEF. FtooD ZONE APN
con❑ Iues.wnewect(See 7 4,L Business
ss an wmmnii...Cade:)Th Commorsm
License
ct the project(Sec. oana Business nod Rafemiens Cade:)The Contracmnd PERMIT ISSUANCE
Licennn Lawdnesnm apply to an nwnerof propeny wM1nbuildsnr impmvcntherwn,and
�whocontmanforsuch projects with a contractors)licensed pursumato the Contractor's ALTER-DRAIN&VEND WA FA)
License Law, FEE SUMMARY
❑'`ton exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.D CE OU OIDE FEES
SANITARY YN
Owner Dam DRAINS-FLOOR,BOX.AREA,CON RECEIPT'#
WORKMAN COMPENSATION DECLARATIONSCHOOLTAX YN
❑ I hereby affirn that l hive a certificate ofconsenno selLinsum,or a certificate of FIXTURES-Phi AP RECEIPT#
Wmkers'Compensation lnsutatce nrocenified copy N<maf(Sw.3800,Leb C.J which PARK FEE YN
Jcovers all employee's..denhis permit. GAS-E S'IEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION I7CES
CompanyAS-EA.SYSTEM O R4(EAJ PLANCHECK FEE
❑ Certified
copy is hereby Finished.
❑ Certified!copy is filed with thecity inspection division. ORPASPJINDU. RI. i INHEMCRI&R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHT SOILS FE-B
COMPENSATION INSURANCE
(T'hisncctinn neat notMcnmpletW iOhe permit is for one hundred doll a($11) E S AR ST EA. FT. ENERGY FEE
or less.)
I certify that in the Performance of the work for which his Permit is issue , shall R I TF�WN.NIB:LECfR
not employ any person in any mermen ao as to become subject a Ner
Ne We n' PAID
Z Compareatirnlawsof Califomia. Date S T.Mi7RPATING Dam Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you shout NEW RESIDENTIAL PLM SQ.FT. TOTAL:
LI) become subject m the Worker's Compensation provislonsofthe Labor Code,you mus BUILDING FEE forthwith comply with such Provisions or this pemtit shall be deemed besidetl.
Y
1 [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agrncy for the perornance of TOTAL: ELECTRIC ItiE n
UO thew...kfor which this permit is i...ad(See SOO,Civ.CJ
lender's Name
lenders Address QT MECHANICAL PERMIT FEE PLUMBING FEL'
T certify that 1 have read this application and state that above information is "
correct. I agree to comply with all city and county ordinances and state laws relning to - PERMIT ISSUANCE. MECHANICAL FEE
rF.t building construction.aid herebyaahosize mpresenad,mi.fthis city to carer upon the CONSTRUCTION FAX
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECH.
s--t (We)agree m save,indemnify and keep handless the City of C.Pert nn against
liabilities'url and.pc.,.w ' i,unywoyaccnrtopeularml l'ty AIRHANDLTNGUNI0CIM)
'F(TO10,00
meq. of Ne drilifflin l
/ HANDLING UNIT(OVER I0000CPM)
Si of Applicant/Commcto Data HAUSTHOOD(WNUCD
PAID
HAZARDOUS MAT17RIAM DISCLOSURE HEATING UNET(TO 100,000 BTU) Data Receipt#
W ill Ne applicant to Lucre huilding necti,mit Bare or handle ha.mdous maanul
as defined by the Cupertino Municipal Code,Chapter 912,and the Healdi ad Safety HEATING ON]p(OVER In),"BTU) TOTAL:
Cade,Section 25532(a)]
❑Yes 11 No VENTILATION FAN(SINGLE:REBID)
000 BTU) ISSUANCE DATE
Will the.pplicum or l'murebuiWing occupant use equipment ordcvices which emit BOILER-COMP(3HP OR 100, P A ' D
taemmm air commitments as defined by On Bay Arta Air Quality Management BOILER-CGMP(OVER 100,000 BTU)
inricIT 111YYY
El yea ❑No NEW RESIDENTIAL MECII. SQ.FT. NOV to 7 1994
1 have rand the hazardous materials requirements under Chapter 6.95 of the //``t V V r u
California Health&Safety Code,Sections 25505,25533 add 25534. I understand that CITY V
if the building does mot canento
ly have a o,om.that it ism,re, mihhtym inotifynCIT'v
a V t O
occupant of the requirement.+which must od met prior m issuenm of a Cenificam of
Occupancy.
Owner m amhmized agent Data TOTAL: ISSUED BY:
OFFICE