26320 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDIELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 26320
BUILDING PROIF.CI'IDENTIFICATION
BUILDING OGRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
6 UNIT ar LOT It
O 1 CO OR'3[JAM LIC NO:
V NIC CONTROLp
�ARCHITECf/ENGIN. LUNO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT .FEE BUILDING PERMIT INFO
RLOG PLUMB ME❑CH
PERMITISSUANCE � �
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DFSCRIPTIDN
CZ Ih?")aRmt Natlam licenvW underproviciom o(Chapar9(commmcingwiN
00 fation]000)of Ui.uric Sof the Busiaessand Professions Code,and my time.is in PANELS
Licaroall reelas effect.
<zVz yl Licenu Class LIC.it UP T0200AMPS
vFi<y Dare Contractor 301-1000 AMPS
ZOy7,ARCHITECTS DECLARATION OVER IOfl0AMP5 SQ.FT.FLOOR AREA Sm.FT.
OZ—D IundcrsmW my plansshallbeusedmpublicamords.
y SIGNS ELECTRICAL
Q 'gl Licensed Professional
C G
OWNER-BUILDERpt from a CormuION SPECIAL CIRCUIT/MISC.
�qax(Oa V 1 hereby affirm that I em exempt from Ne CnntrvnMe License law for she
W 3 a ti following rea em.(Section 7031.5,Business and Profusions Cade:Any city or county TEMP.METER OR POLE INST.
�,� which requires a permit to consumer,Wer,improve,demolish,or repair any stmcmm
tVy'�Y� prior a its issuance.slso".1.,Nevpplicant for such permino file aligned stenlem POWER DEVICES
y)C p that he is Iicenaul pursuant 10 the pavisiom of the Connector'.License Law(Chapter
4 0�' 9(commencing with Sectio,7flic of Division 3 of the Holiness and Professions Code) SWIMMINGPOOLELECfRIC /� VALU
yYj'^y or that he is exempt and the basis for the alleged exemption.Any violation of OUTLETS
-SWITCHES-FlXTIIRES �� ) C)
ZQ Section 703 L5 by any applicant for a pennumbjets the applicanuoecivil penalty of G..
f
thanfivehundred dollars(3500). NP.WRP.SIDENTIAI.ELECTR S .PT.ownttolthe properlyormyemployes withwegumthcirwlecompemadanQ STORIES TYPF;CONSTRUCDON
ework,andNesusions Cade:The Comsachm's License Law does not apply to an owner of
whobuildsadmproves hannean,arrdwhodoxsmch workhimulforNrough his
oyees,providedthnrsuch impmvemenmvrenot intended araffrW fnrsele.ILOCC GROUP RES.UNITS
she building or improvement is cold within one yearofcampletion,tbeownen .ro
builder will have the burden ofproving Nat he did call build or improve for purpose of
sale.). -
❑ 1,esawnerofthepmpmy,smexclmivelyconnutingwiNlicensedconuactomto QTY. "PI:UMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7011 Business and Professions Code:)The Contractor's
License Lawdocswtapplyemownerofprapenywhobuildsmimproves Nermn,and PERMITISSUANCE
whome mmafor such projects with acontrmmr(s)licensed pursuant to the Contmcerrs
Licenu Law. L v T (F FEE SUMMARY
❑ 1 am exempt muter Sec. ,R&P C for this reawn (n+� (— UT,ID S
' SANITARY Y N
Owner Date a - .I R E C E I p
M
WORKAN COMPENSATION DECLARATION I' D INS-MOO ;ROO �AREA,C SCHOOL TAX YN
❑ I hereby ani
a
that l havecertifcteoco
fmem a sel4inmmin.cenificamof RECEI p
P
Warkers'Compenation lnsuranceoracertified copy Nereaf(Sa.3800,Lab CJ whi4h a PARK FEL: Y N
ars all employee ieasier this permit, - ,(,SYSTEM-I IN040 TS
REC'PTp
Palicyp BUILDING DI SIONF
Company GAS-EA.SYSTEM-OVER4(PA) PLANCHECK FBF.
❑ Cenified copy ishereby famished.
❑ Cenifietl copy is filed with the city inapation Jivisian. GREASUINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action need not bemmpleted ifthe permit is foronehumdrnidolhrs(SIOo) SEWER-SANITARY-STORM EA.200FT. ENERGY
or less.)
I certify that in the performance often work forwhich this permit is issued,l shall WATER HPATER W/VENIELECI'R
not employ my person in any mourner so m to become subject to the Workers' PAID
Capmetabo Lmscof Califomin, Data WATER SYSTEM/TREATING ate Receipttt
O z Applicant
'y7 C) NOTICE TO APPLICANT:IL eller making this Cerifirri Exemption,ymImmild NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
P tibecome subject to the Worker's Compensation previsions ofthe Labor Code,you must -
1 foMwith comply with such provisions m Nis permit shill h damM revoked. BUILDING FEE IL
Ila Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I heteby affirm Nat there is a mmtrumiodi
m lenng agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ME
Isnder's Name
C)U Lenders Address QTY. OCHANICALPERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is -correct. re m MECNAMCAL FE
l ogre comply with all city and cowry ordinances and sue laws adding to PERMIT
built ingeonstruction,and hereby authodae representatives of Nis city to mer upon the CONSTRUCTION T
V 7-. above-mentioned properly for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,' if,and ken the City of Cuperlimo against
halt I I es,judgnme ' dexpmea anywaywcrueagainsuaid City AIR HANDLING UNIT CO IO,000 CFM)
snting of In ,I
YAIR HANDLING UNIT(OVER 10,000 CFM)
nemre of Appta anwm De EXHAUST Ht30D(Wp)UCD PAID
HAZARDOUS MATERIALS DI LOSURE
HFATNG UNIT LTD IOQIXID BTU) Dam ciptp
Will the applicant or future building occupant stere or hurdle hoe Health
a material I IEATNG UNIT(OVER 100,0110 BTU)
dill.Sed by she Cupertino Municipal Code,Chapter 9.12,and the Hmlth and Safety
Code,Section255J2(a)?
13 Yes 13 No VENTILATION FAN(SINGLE RESID)
is
BOILER-COMP(3HP OR 1011,000 BTU) [J P—R NICE DATE
Will air contamtorfut be building by Ilenmu Area it(lustily Management
t /Ir N/8i 1994
' hurardoos air contaminants m defined by the Be,Area Air Quality Menngemem BOILER-COMP(OVER 100,000 BTU) v 1a%s%
)isuict? b
❑Yes El No NEWRESIDENTIAL MECH.—SQ.FT. + Qr (a(drrhinv"
1 have read the hazardous materials requirements under Chapter 6.95 of the V
Califmnia Health&Safety Code,Sections 25505.25533 and 25534.I understand that
if the building does not currently have a tenan6 that it is my responsibility to notify the
occupant of the requirements which must be met prim m issuance of a Certificates of
Occupancy. <::� F��)
Greater or authorized agent Data TOTAL: ISSUED BY:
OFFICE