27214 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOISUBAILING-IrLMTRI A. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. A H A
14
BUILDING PROJECT']DEN OFFICATION L
BUII,IIING ADDRGSS:t � SANITARY NO. APPWG'HON SUBMTITA ATG
'
Via_� /1/a q /� IINITa / l"p LOT. .37
O/ �tSjJA is I' 4 /4r*r_ePHONE' Q O0 CONTRACTOR'S NA�M�E�m e.- LIC NO:
-- /S;A low '�S/V_P/ a9 N/C CONTROL It
• ARCHITECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE:
//� QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
d/ee V0O Pr yot gSrs-606/ PERMIT ISSUANCE BLDGCSr ELECT PLUMB MECH
LICRsTSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
pKz I hereby affirm that l am licensed underprovisiormof Chapler9(commencing with
tt full Ione addefDivisionJof the Business and Professions Code,and my license is in PANELS
yZ, fullnseelasseffect.
Fyty License Class Lica UP T0200AMPg
y6y Data Contractor 201-10010 AMPS
Fy z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA 9SQ.FT.
ZO z yQ I undersand my plans ahold be rated as public records. OVER IIg10 AMPS
SIGNS ELECTRICAL /13s6
Licensed Professional
tel OWNER-BUILDER ION SPECIAL CIRCUIT/MISC. P
KOaF I hereby aRnn that l on exempt from thecConlmctora License law the
FW�O w following reumm.(mm,to com sect,slaws and Professions h.oe:Aay city n....nry TEMP.METER OR POLE INST.
" m a] which requires n permit re mnswn,aper,improve,demolish,or repair any struenrc
pal 00 barher to sficeuance.alsonnamrequires the dre visios t for afthe ch Commacmea file a License
La statement POWER DEVICES
w(Chapter
ta.a O Nm he iscnwithsed Suanno")Of provisions the Ce Business
and
Prestionsode)
WM, 9that(commencinghisxemithSection Tl00lof Division Sof theed exemption.
ProfessionsCade) SWIMMING POOR.ELECTRIC VALUATION
yp_a ontion7031.5bynherefromntforaPerand the mitsubjfor easegedexemptloo. civiny lPnaltyof OUTLETS-SWITCHES-FIXTURES ai6 as9,
F z_>' no[Section v any
undredidont B$50nnit subjects the applicanuoacivil peachy of
Tp l,a than rofheproW ny,ormyem). .�
I,asnwnernfrhe n y p y g pe NGW RESIDLM'IAL ELECIR _SQ.PT. STORIES TYPE CONSTRUCTION
R pw m❑ props y,trm cm to eilorafere csastheirsolec0m araban,
will Ju lesions ende:The Comcturemerceot.
License Law doesed not
apply
to a4,Business
and Professions GoJ<:The Conmcmrs License Law does not apply to an owner of
prnpenywhobuildsorimpmveslhereov,and whodoes such workhimselfordmaugh his OCC.GROUP RES.UNITS
own employees,provided that such improvements am not intended m offered lou rads.If,
however,the buildingmimprovement is sold withinone yearofcampletion,theowner- OTAL:
builder will have the burden of proving that he did not build or improve for Purpose of
sale.). QTY. PLUMBING PERMT .FEE FLOOD LONE APN
EI I,as owner ofthe propeny,amexclusivelycommcting with licensedeminacmrsto
consracl the project(Sm.7814.Business and Professions Code)'The Contractor's
License lawdocs notapply man owncrofproperrywhobuilds m improves common.and PERM]TISSUANCE
who commas or such projects with.coneaelor(s)licensed puts..nuathe Conbactor'r ALTER VENT-WATER EA
License law. TPA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK MOW PROTECT,DEVICE 'ID
SANITARY Y N
Owner Dam RECEIPT.
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,ANEA,COND. CHOOL'1'AX YN
❑ Iberehy uffmm that(have ucenificate of consenno self-insure,oracmificme of RECEIPTp
FIXTURES-PER TRAP
Wmkeri Compensalionleoracenificd copy Nerwf(Sec.Jg00,Lab CJ which TANK FFMHY N
covers.11 empinyee'r undere,this This permir. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTM
Policy a BUILDING DIVISION PEES
Company GAS-IIA.SYSTEM-OVER 4(EA) PLANCHECK FEE �—
❑ Certified copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASEflNDUSTRL WASTE INTERCEPTOR GRADING FEE
CF.RT'IRCATF.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not he completed iflhe permit is(oras hundred dollars SUR) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Icss.)
I certify that in the performance of the work far which this pemrit is issued,I shall WATER HEATER W/VENT/ELECIB
nes employ any person in any manner so as to become subject to the Workers PAID
Z Compemmom Lawsof California. Data WATER SYSTEMRREATING Date Rettiplp
Applicant
y�y0 NOTICE TO APPLICANT:IL after making this Ceniftcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
C7 (q become subject to the Worker's Compemation provisions of the labor Code,you must
� ; forthwith comply with such Provisions or this Permit shall he deamed revoked. BUILDING FEE q /—
C31 A CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a construction lending agency for the performance of
U O the work fm which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ME Q' 1 vs r
Lemice,Namt,
O F Lcndels Address PLUMBING PEE v
QTY. MECHANICAL PERMIT FEE /6-31
58'
V I certify that 1 have lad this ep,lt.1i..and snot,that the above information is 3a 1577" W correct.l agrees to comply with all city and county ordinances and state laws reL FE
relating to PERMITISSUANCE MECHANICAL.
UF-' M buddingeonvtruction.and hereby radiative rcpmsentativesofrhis city to enter upon the CONSTRUCTION TAX
7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Ma
(We)agree to save,indemnify and keep harmless the City of Cupertino against /T
diabililiea,judgmos
ems,cm and expenses which may toot me against said City AIR HANDLING UNIT(TO lO."CFM)
inJ frhoegrntingofNispsrmil. ffz4'�95
c�//, 1 gypout / AIR HANDLING UNIT(OVER 10,000 CFM)
Signaturelicant/Co tmcmr Dam EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE BEAT[NO UNIT(TO 100,0081 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazarvous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safely ITHAI'ING UNIT(OVER 100,010 BTU) TOTAL:
Cale,Sc<ti 25532(a)P
0Yrs ❑No VENTILATION PAN(SINGLE RESID) IV
ass'
ISSUANCEU_ATEE
Will Neappiicantorfunmbuildingoccup.nluseequipmeunmrdevicowhichemit BOILER-COMP(3HPOR 1010,00(1 BTU) IY
havmdous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0011 BTU)
DislnG? 13 JAN 24 198,5
Ycs ❑No NEW RESIDENTIAL MECH. gQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the Cl/Y
California Hualth&Safety Code,Sections 25505,2553]and 25534. I understand that Vf
if the building does not currently have a tenant,that it is my responsibility to notify the U1 Lif j'(/INV
occupant of the requirements which must he mel prior to issuance of a Certificate of
Occupancy. '
lcz7eOwner sur authorized agent Date TOTAL: ISSUED BY:
OFFICE