26505 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BITTEDusir.- '" PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL. C C O
BUILDING DIVISION BUILDING PROJECT'IDE,NI'IF'ICA'I]ON o f J
BUILDING ADDRESS: �p !Y SANITARY NO, APPLICATIONSUBMITTALUATII
soot �ME: �� /• — v �� Ulst LOT# ^/}/ �i•���,t try^��
O ji(O�AC/'/ yFL•f�r (yOP� NB: O C700S0RWM7 NIC CONTROL
RCI III'I'ECpFYGINEER: LICNO: ADDRESS /rs�r/`q'� ,Jy - ❑
ffillty
:ON]'ACI'; PHONE: QTY. t;"EI' iECT' RiC PERMIT FEE
' ' BUILDING PERMIT INFO
r .I,.
- BLDG ELECT, PLUMB MF.CIi
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz I hereby affirm that l am licensed underpowisionso'Chapter9(mmmenciagwith
1 {x100 Section 7000)of Division Softhe Busiaeas and Prefeuioos Code,and my licame,is in PANELS
f icomee and cffec 1
C v-g�.3✓rT UP T0200 AMPS
FQ-ZW Danse Class r4B1Lic.p
rn6Z
Data GOeT'SD 201 OVER 1000
Fy_Z ARCHITECT'S DECLARATION — -- SQ.Fr-FLOOR AREA E/SQ.FI'.
ZO0'_
N_ I understand my Plan shall M used as public woods. OVER 1000 AMPS E 8 ,f
"P— SIGNS ELECTRICAL EI t s Gam.
Q,l Licensed Prowhereby
aiomal
'Sty 'V OWNER-BUILDER DECLARATION SPECIAL CIRCUfryMISC.
WE—on _I hertM1y affirm that 1 em exempt from the Contractor's License Law for the
W 3 W m following reason.(Section 7031.5,Busincsa and Professions Code:Any city or county TEMP.METER OR POLE INST. 1^/
cqcq..f50� which rcquires a permit to construct,alter,improve.demolish,or repair my structure
DEVICES
ure a ,�
2NY7 Prinrto its i.suance,also requires the applicant nonsuch pemtittofile aligned statement _ �-
gtejapr[ that he is license)pursuant to the provisions of the Connector's License Law(Chapter#'j�Qo tv. ')(commencing with Section]DDO)of Division of the Rusinns end Professions POOL ELECTRIC
Code) VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of Of1T1.E1'S-SWITCHES FIXTURES
k Z Q Section 7031.5 by any oppheant for a permit subjects the applicantto a civil penalty of - +,
� G
not more then five hundred dollars(5500). NEW RBSIDENTIAL ELEC 11 _SQ:FT.
CC m ❑ Loa owner and the
a,..is
no,in odm .Tiered for hei(Ser. 04u,Buxisea. STORIES TYPE CONSTR CI'10
Wa3- will dude work.ands:Tin,Creism?a License La a does sal apply1 son w.,,of
and property
obu ldsor:The Costndors License Law such
oat apply tort owner of
pmperyw eel,psorimprovesthemprove whodoessuchwork himrelfor through his - OCC.GROUP RES.UNITS
ownempinyas,provided thatsuchimpmv<memavre not imcndedaoffertd forsale.If,
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ I,as ownerorthe property,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
runstruct the project(Sec.7044,Businaas and Professions Code:)The Contractors PI3RMIT ISSUANCE -
L.iccmc Law Jocsnorapply m aoowner of properly who hands or improves thereon,and
LicemwALTER-DRAIN&VENT-
Luw.
mamforsuchprojects withacomrector(s)IicensedputsuuntmNe Conuazm/s
LiccnmWATER(eAJ FEE SUMMARY
m ,❑ lamexempt under Sec. ,B&P C(or This rcnson BACK FLOW PROTECT.DEVICE I3 sMRS
SANITARY Y N
Owner Data RECEIPT#
DRAINS-I1.00R.ROOF.AREA,COND.
WORKMAN COMPENSATIONcdcame ttowlfATION SCHOOLTAX Y N
❑ ara'Co affirm that Imu anccor ifcae ofcovenurandf(ee.38or acanific teofhick RF.CBIPI'p
F[%TURBS-PER TRAP
Warken'Compenwionlmurena araunifedmpy thertof(Sec.3800,Lab C.)which PARK FEB YN
coven ell mtployyc'zupder�pia pymit. GAS-PA.SYSTEM-b INC.4 OUTLETS RECEIPT S
Iblicyp JN N�!/JBUILDING DIVISION FEES
Cmnrymy ' _An GAS-EA.SYSTEM-OVF.R4(EA) PLANCHECK FEF:
❑ 12ifcJ copy is herewithby tie city
Cenilicd copy is filed with the city inspection division. GR[A9PJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHIRAP SOILS FEE
COMPENSATION INSURANCE?
(This section need notbe completed Unto Permit is for one hundred dullest(31011) SEWER-SANITARY-STORM EA,20l ENERGY FEE
or las.)
I rectify that in thcperformence oftbe work for which this permit is issued,)shad) WATT � W/VENT/ELECfR
not employ any Person in any manner so as to become subject to the Workers' PAID
Compensmionlswsof Califumia. Data WAIF. SYSTP. EA'T'ING Da¢ Receipt#
O Z Applicant
Z 0 NOTICE.TO APPLICANT:IL after making this Ceraificme of Exemption,you should TCft!EMIAL PLMB. SQ.PI', TOTAL:
f/] become subject m the Workers Compensation Provisions ofthe labor Cale,you must
f nchwitb,amply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Uj Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the perform.of
Vr the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Landers Name
O U Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I lenity.thus 1 have read this application and smm that the imove informed.is
correct.Ingrcctumcmdywithall city and county ordinances and state laws relating toI'IiRMIT ISSUANCE MSCI IAN[CAL FEF.
�^ buil ding construction,and hereby authorize repssmandives of this city to enter upon the CONSTRUCTION TAX'
V 'Z move-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wel agreem save,indemnify and keep harmless the City of Cupertino against
Iiabilineaj g rus,ro,voesp,mas which n y in my way seems ag nst si City AIR HANDLING UNIT(TO 10,000 CFM)
in cmruy n fthe ng of 's. I .#
Aw10 AIR HANDLING UNIT(OVER I0,010 CFM)
Signor Applic- ommcr / Dm EXHAUST HOOD(W/DUC ,
PAID
HAZARDOUS MATI7RIAIS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
ill the applicant r future building occupant sere or handle hamokous material HEATING UNIT(OVER 100,000 RTU) TOTAL:
as def trd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safe,,
Code,genion 25532(x)?
❑Yen ❑No VENTILATION PAN(SINGLE BESIDE
ISSU�AN„HaF,DATE
WIII fitimplicunmrfutumbuildln BOILER-COMP(3HPOk 100,000 BTU) 1�,JjI ,
g occupantme Ate&Air Quality
Maraghemit
hnanlous air contaminants as deGnrA by the Rey Arta Air Quality Manegemenl
BOILER-COMP(OVER 100,000 BTU)
��1 9iariml ❑Yes ❑No
NEW RESIDENTIAL MECIL SQ.Fr. JUL 291994
1 have read the hazardous materials requirements under Chapter 6.95 of the �j
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that Cin' OF (iUf'tHIINII
if the building does not mora iy have a mnmt,that it is my remonsibiliry notify tify the
O cupan of the requiremenm which mon be met prim to issuance of a C<nifimte of
Occupancy.
Owner or amhanacd agent Udte TOTAL: ISSUED BY:
OFFICE