24600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
NUILBING-ELECTRICAL. PERMITNO. O O
CITY OF CUPERTINO PLU.VIISING-MECHANIC L
BUILDING DIVISION APPLICATION/PERMIT
,BUILDING PR(1dBCT'IDENTIFICATION: s
BUILDINGADDRES�S . SANITARY NO. APPLIGATION SUBMITTAL DATE
�� K/ � 1f_1 � �NIT1'N T LOTH ^i�111`rM
OWN AMP.: P CONxRCTO
AR'S NAME: w� LIC NO:
(�/ //elf !T_/ N/C CONT$OL IL
�CHITECT GINEER: L NO: AFQS $/T`F/7/1■„�"/\I
YJ
CONTACT: L� PHONE: 6T' t s' ELECTRICPERMIT!t xFg.r-.; - - BUILDING PERh11TINFO -
PLUMB MCH
PERMIT ISSUANCE,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
MZZ I hereby affirm that l an licensed underprvislons of Chapmr9(commeneingwith DESCRIPTION
�00 Section]000)ofDivision3of the Business and Professions Code,and my license is in PANELS
W dl fame and affect.
UPT020p AMPS
I,icenu Class Li,.
m 6� Data Computer— 201-1000 AMPS
ZO
F yrira OVER IOW AMPS
ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
-
I undersand my plans shall be uned as public records.
�`~� Licensed SIGNS ELECTRICAL !(Licensed Professional
mm
OWNER-BUILDERDECLARATIONthe Co ATION SPECIAL CIRCUIT/MISC.
hereby affirm that I stn exempt from the Cossimas io e:A,o Law for the
W 3µ•m whichfollowingeq reel ape mit to construct,
t,sines and Professions Cole:My city or estray TEMP.METER OR PoLF.INST.
which requires n permit re quires the
alter,improve,such
demolish,m repair any structure
T� prior to its issuance,also require,the applicam for suchprnnino file asigned statement - POWER DF.V ICES
4 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 offs,Business and Professions Cade) SWIMMING POOL ELECTRIC ^ V/AALLU�ATTION
-,so orthat70sexempnherefrom and the basis foMeallegetl exemption Any violation of UTLETS-SWITCHES-FIXTURES �� /
L. a Sce=p03156yanyapplicantfor a permit subjects the applicannoecivil penalty of r J
ct
not more than five hunAred dollars($500). .
[II,asownerofthepropeny,ormyemployeeswifhwagesusthelrsolecompensatlon, NEW RESIDENTIAL F.LECTR S QFT. STORIES TYPE CONsTRUCT10N
will dothe work,and toe structure ism,ortardedoroffered m,Vde(Sec.70,PL Business
! and Professions Code:The Contmuor's liter.Law does not apply to an owner of
property who builds or improves thereon,and who does such work himxlf or through his '
own empleyees,provided thatsuchimprovements arommintended oroffered forsale.If, � OCC GROUP p .UNITS
however,the buildingor improvement is sold within one yearofcompletion,the owner
erdid.,
- 1 J II .p T •_ R
buildwill have the bmpbm fprovingthat he did not build or improve forpure,we of V Y
Bale) P x -�
„Py -LUMBING PERMIT- tea T';FEB: -E FLO APry
❑ I,as ownerof the property em exclusively contrera ng with lensed commnurst QT '?-* _
omannet die proem(Sec 7044,Business end Professions Code)The Cmntruclo s
Licenselawdoes not apply to an ownerofprperty who bolds or improves thereon and PERMIT ISSUANCE t I'
whocontmcts for such projects with acomraetor(s)licensed pursuant to the Contractor', ALTER-DRAIN&VP,NT-WATER(EA) �s +-t' - -A
License Law. ) �p =0x s§FEB SUMMARY;,"
❑ 1 nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES s
SANITARY Y N
Owner Date DRAINS-FLOORROOF.AREA,GOND. RECFIPTN
,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y - N
1 hereby affirm that I base a certificate of consent fm self-insure,or a certificate of RECEIPT W
..rkam'Compen.safion Insurance or acertified copy thereof(Sce.3800,Lab C.)which FIXTURES-PER TRAP 13 PARK FEE Y N
rs ell employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS - RECEI N
Pollica BUILDING DIVI. ON BEES
any GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
Ca,Hand copy Is hereby famished.
filed copy is filed with the city inspection division. GRFASE/INDUSTRL WASTE INTERCEPTORGRADINGFEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREAS_ETRAP SOILS FEE
COMPENSATION INSURANCE
(Thlsscatlon need notbecunitced lfthe permit is formic hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE ssq
or less)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER WNE.NT/F,LECTR
not employ any person in any manner so as to M1ecome subject to the Workers' PAID
Compensation Laws of California. Dae WATER SYSTEMITREATING t - Recei
Z0'7
NOTICE tTO APPLICANT:If,ager making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
r? rq become subject o fee Workers Compensation provisions of the Labor Code,you most -
F�i ; forthwith comply with such provisions or this Permit shall be deemed revoked. BUIL FELE.
IF,W I CONSTRUCTION LENDING AGENCY S S BE
✓✓R I harmyuffirm that then isaconstruction lending agency forthe performance f
U Z the work for which this Permit is issued(Sec 9097,Civ C) L TRI FEE
Lander s Name d e, k s.,:g q y n y m-k r
GIs Under naaress 4MFCHANICAL{PERMITn 3 t s s P�1F.EE)2+ PLUMBI GPEE
ttV :S'ie: m.,M„ @w sr:x -4 Sas
I wngr that 1 have rend his ny a wdoo and state that the above law,
information ie MECHANI AL E
cnrect.lagreetoeomply with ell city and county oNinancosand vmale ifymawsrelaiog to PERMIT ISSUANCE ��
mosergcoflimed iomandhercbspecti rizempapax. Ives of thiscitymebterupon the - CONSTRUC TAX
C) ahnv(Wentioned property indemnify said purposes. ALTER OR ADD TO MECII.
(We) w eve indemnify and keep harness the City o Cupereagair i,against City
liablll' ,)udgi ,costs andexpenseswhlch may in any way auue against seiJ City AIR HANDLING UNIT(T010,000 CPM)
n cons�
AIR HANDLING UNIT(OVER IO,INIO CFM) 5
Signature of APplicant/Contmctor Data EXHAUST HOOD(W/DUCH ) 2
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEA'L'ING UNIT(TO IO0,O00 BTU) • fie Receipt"
Will the applicamormarm building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOT L:
as defined by the Cupertino Mmp ro"d Coda,Chapfar 9.12•and the Health and Safety
Code,Section 25532(a),, �V,[`/ VENTIL
❑Yes ATION FAN(SINGLE RESID)
9
Will fheapplicantorfmlurebuildinguccupant useequipmlm
enrdevices which emiHOILER-COMP UHP OR 1Og0W BTU) A
t ,TE
rdous air contaminates as{1�fined by the Bay Area Air Quality Management MAR 5 .1993
- / BOILER-COMP(OVER IOO,WO BTU) 14 m
❑Yes ID'N NEW RESIDENTIAL MPH. SQ.FT.
4 I have read the hazardous materials requirements under Chapter 6.95 of the CITY Ur 1tUfCf1111YV
California l lealfh&Surety Code,Sections 25505,25533 and 25534.I undersand the[ !—
ifthebui tithe it is my respnnsihility to notify the
which mus poor to issuanc f n Certificatef o -
Owner ter authorized agenfn DateL: ISSUEDBY
OFFICE