26026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ELECTRICALBUILD NO- PERMD'NO. f� c //�
BUILDING DIVISION APPLICATION/PERMIT PING FROJECTICHANICAL 2 6 O L E
;`:..a'.=::<� BUILDING PRWECI'IDENTB'ICATION. ::
5ILDING
G ADDRESS: ♦� /� b� � �t1 SANITARY NO, APPLICATTIoNNsufaln7AL DAT
Iv1S1 ✓s UNIT It LOT# ts—A2e s
EY NAME: M� PHONE: CONTRACTOR'S NAME. LIC NO: W
(( AS;.. NIC CONTROLN
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
kc," LWgm C-1 0% 3
CONTACT: PHONE:
CC,,� QTiY:$"Md r2NA*ELECI-R+IC- IaT
"BUILDING PERMIT[NFO
PERMi,
sm^ c BLDG ELECT PLUMB MEC)
PERMIT ISSUANCE ��aT►/TT.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTON
Metz Ihereby affirm Nal l an licensed under provisions of Chapter 9(commencing with _
WOO Section 901 of Division 3 ofthe Business and Professions Cod,and my license is in PANELS
04 U full force and effect. \
<Z::1 Lncme Clans Lica UP TO 200 AMPS
vFi j y Date Contractor 201-IOW AMPS SQ.FT.FLODR A %IgQ.M.
,Z��Z ARCHITECTS DECLARATION OVER IQM)AMPS �RyE.q
OZ—M l understand my plans shall be used as public records. pO�y
_yFm SIGNS EL ICqu,� i� -- 11 y Ll W
Licensed Professional
E:ow, OWNER-BUILDER DECLARATION SPECIAL RCUIT7MISG
XO y U I hereby affirm that 1 an exempt from the Convmtors License Low for the tl
XW fallowing mason.(Section 7031.5,Business and Professions Code:My city or county TEMP.MAMR ORIOLE INST.
< which requires a permit to commact,alta,improve,demolish,or mpah my structure
pdermiu issuance,also mquims the applicant for such pemitto file asigned statement POWER DEVI
L0 Nn he is licensed pursuant to the provisions of the Cmtnctor's License Law(Chapter
aSW G POOL EIECIRIC
�E 9(cotmncncingwith Satiml000)of Divisim3ofthe Businnsand Professions Code) 9 VALUATU
til-'m or that he is exempt therefrom and the hasisfor the alleged exemption.My violation of UTLETS-SWITCHES-FIXTURES
e.Z< Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of
E-M 3 I.now rofve e hundredd .or (ympl NEW RESIDENTIALELECIR —SQ.FT. STORI ' TYPECONSTRUCTIO:
�_� n❑ Lasowncroftheestracy,ormyempindedorthwagessstheine(Sec.70mpensstion,
y3— will dothework.Cde:noCmeisnoris License Law
Loan.Business
end Profession Code:The Contractor's License Law does or apply tom owner iof
s
propertywhobuildsarimpmvcuthereat,andwhodorssuchworkhimxIforfor e.his
own employces.provided thetsuch improvemcnrsmenot inxndedarofferedforsale.IL OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofmmpletion,theowner- a,,-
builder will have the burden of proving Nat he did not build or improve for purpose of ,.� _
�c)L asownerof the QTY b+ i-I;La, PLUMBING PERMITY- a,fwf '; FEE FLOOD ZONE APN
[IpropmY-amexclusively contracting with licensed contractors to t;v,'>au t*..
contract the project(Sec.1014.Business and Profession Cade:)The Convector's PERMITISSUANCE ���
Ucmsetawdmsnmapplymmow crofpropertywhobuildsmimpmvesthemm.mil
whoemmcisfmsuchpmjecuwithaconacos)Iicensedpunumtiolhe Coni=es I ^,� . y;t„
License Lew. ALTER-DRAW&VENT-WATER(FA) - :',,'kSt'„�.i .�>•ki•FEESUMMARY,f! -v -
❑ I am exempt order Sa. ,B&P C far This reason BACK FLOW PROTECT.DEVICE m h UTSIDE FEES
SANITARY Y -
N—Own" Care— DRAWS-FLOOR,ROOF,AREA,COND. RECEIPT#
j WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ 1hereby sffum than l have a certificate tt
ofcomeno self-inate um,or a sanificof FUCTURM-PER TRAP RECEIPTp
4 Workers Compamation lnuraifi
nce or a candied copy themu'Rec.3800,Lab C.)which PARK FEE Y N
covin Jlemployeesmil,, osperms GAS-EA.SYSTEM-I INC.4 OUTLETS RE
Policy# eU DIVISION
ION
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK
❑ Certified copy is hereby fumishod.
❑ Certified copy is filed with the city inspection division, GREASEANDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETIUP SOILS E
COMPENSATION INSURANCE
(This section neednot be,completed lithe permit is for one hundred dollars($101) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m leas.)
I minty that in the performance of the work for which this permit is issued.)shall WATER HEATER W/VEN'T/ELECTR
not employ my person in my manner so as M become subject to the Workers' PAID
Z Compensation Laws of Califomia. Date WATER SYSTENUTREATING Dem Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject o the Workers CampenN.provisions of the Labor Code,you must
7 foMwith comply with such provisions or this permit shall be deemed revoked. BUB-DING FEEhi
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U
1 hereby affirm thatthem is a com miXtmm lendin a enc for the performance of Z y g C y Lam ELECTRIC FEE
U (] the week for which this Permit is issued(S .3097,Civ.CJ aA
.. Lenders Name w' ?" qps? k. "y PLUMBING FEE
E" Lenders Address QTY C{eyG _MECHANICAL PERMIT> 25*-R:t, FEE, „
U I cmify that 1 have read this application and slam tont the above Information is "'-' MECI IANICAL FEE
rT" canact.lagreetommplywithellcitymile...tyardinancesandaarelawsrehoingto PERMITISSUANCE
I"' y building conswction.and hereby minion representatives ofthiscity toenmr upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hamiless the City of Cupertino against
liabilities,judgments.o.eis mdexpenses which may in my way amort,against said City AIR HANDLING UNIT(TO I0,t100CFM)
in mnsegoemce of the granting of this permit.
' AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanUCmvacmr Dale EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO IM,"BTU) Dam Receipma
Willtheapphnnter future huilding occupant antero,handle hazardous materiel HEATING UNIT(OVER IW.dfq BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Seen.25532nd? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will Neapplicmmrfulom buildingoccupamusecquipmcnm ordevices whichemit BOILER-COMP(HIP OR IN.W0 BTU) p
• ,hazardous air conuminmts as defined by the Bay Arta Air Quality Management BOILER-COW(OVER 101.00)BTU) �+ „ D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read
the hazardous materials mptonement under Chapter 6.95 of the JAN 2 5 1994
Califomia Health&Safety Code.Sections 25505,25533 and 25534. 1 understand Nat
if the building does nm mren0y have a mnmt,that it is my responsibility ort notify the +
occupant of the requirements which must be met prior to issuance of a Certificate of �1%'CI IY Ur 1/ur '/J
' thcuPmcY. fir!
Owner m autharizcd age., Dam TOTAL: ISSUED BY
OFFICE