26240 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO
13.11II C-ELEC'1'RI AL PERMIT NO.
APPLICATION/PERMIT PLUM BING-MECIIANICAL n C n /I 0
NUILDINf.DIVISION BIIILDINC PNOJFC'1'IDEN'TIFICA'I'1I5N G v G s{
BUILDING ADDRESS: SANITARY NO. APR.hCATIIOONNSUBBM''ITTALDATE
OI197
E
UNIT LOT
OWN PHONE: UNRACfOR'S NAME:
521,2-11'J N/C cormcol.#
A C rte /ENGINEER: LIC NO: ADDRESS: ❑
o tz� a Lam«- G o LL -101
CON AC'f: PHONE: v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
PLUMB CH
P[RMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL rN
JOB IWSCRIPTION
pmz I hereby affirm that l am licensed underprovisions ofaripter9(commencingwith
n100 Section'la(gp of Division 3 til'the Business and Professions Code,and my license is in PANELS
<'U- Licel eandeffecl.(Z 1ic# 31 # UP To 200 AMPS
p"'f License Cl QP�' !J 101�
;<,- Da¢ 4��Conrn� 201-I"AMPS
F-,Z ARCHITECTS DF.CLARAI'IONSQ.FT.FLOOR AREA $/SQ.FT.
oz I understand my plans am][h used m public records. OVER 1000 AMPS
F y SIGNS ELECTRICAL 111l1111����
Q.N�j Licensed Professional
�tXJ'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.%Oi I hereby affirm that 1 em exempt from Ne Contractor's License Lnw for the
W 3 R y which recanreason.
Permit
to con 1.5,Business and Professions Code:Any city or county TEMP,MEf[R OR POLE INST.
C 0; which inquires a permit to conswn,alter,improve,demolish,or repair any structure
W pricrto its issuance,alsonquires the applicant for such Permit file asigned smtement POWER DEVICES '
1_ q) Nat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
ap�d.o4 9(enmmencing with Section]000)of Division 3 of Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
u1�m or Sechat tion 7031.5 by my
mnt f the Punct subjects thedexemption.Any violation of UTIETS-SWITCHES-FIXTURES 6� )
f. 4aSection 7031.5 by any applicant forepermit subjects the nppli<anno acivil perultY of
O not more then five hundred dollars($501H. .
a ❑ I.mownerofohepropeny,ormyemployttswithwaguwtheirsmlecom oration, NEW RESIDENTIAL ELBCfR -5QFT. STORIES TYPECONSTRUMION
m will do the wark,and thcnrunure iximintendedmoffered for sale(See 7094,Business
and Professions Code:The Cmmracmts License Law does not apply to an owner of
property who buildsarimprovesthercon,rand outdoes such work bimselforlhrough his
OCC.GROUP RI35.UNITS
wnemplthees,din idedduosuchimprovemenksarcnot ine earofo moffered forsale.IL
however,thehave
l the burden
of ement is sat he within of build or impar letiox,l urpose f L:
builder will have the M1urdcn of proving that he did not build rr improve fm puryou of
role.).
❑ I,esownernfdmproperty.amexclusivelycontrectingwithlicrnsedcrnwctorsm QTY. PLUMBING PERMIT FEB FLOOD ZONE. APN
consumer the project(Sec.7004,Business and Professiow Cade:)The Contractors PERMIT ISSUANCE
License 4w doesnot apply In anownerofproperty who builds or improves there rranJ
who contracts formch protect.with acommenr(s)licensed pursuant to the Comma 's r �en�
License Law. ALTER-IRAN,@s�l?n rv, A ) FEESUMMARY
❑ 1 am exempt under Sec. B&P C for this rtason O SID FE
BACK FLOW OTECI'.DEV ICE t� SANITARY Y N
Owner Date DRAINS-PL ;ROOFIA RECEIPT#
WORKMAN COMPENSATION DECLARATION SCfI OL TAX Y N
❑ Ih<rtby affirm thatlluveecenificetc ofcomenuo xlf-imurt,macenificam of G RECEIPT#
Workers'Compensation Insurance at acertified copy thereof(Sec.3800,Lab CJ Fl%TU S-PERT which E PA FEE Y N
cu.crs ell employee's under this permit. --
RECEIPT p
Pot icy# GAS-EA .4 BUILDING DIVISION EELS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ Cediiedeopyishembyrumished,
ACenifiadcopy,isfiled with the city inspeaeicndivision. GRE-ASE/INDUSTRLWASTE INTERCEPTOR GRADING FER
CERTIFICATE OF EXEMPTION FR OM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(This section mariner be completed if Ne permit isfor one hundred dollare($100) SEWER-SANITARY-STORM EA.200F1'. ENERGY FEE
or less.)
I certify that in the Performance ofthe work for which thispmarb is issued.I shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation Lawsof Califomia, Data WATER SYSTEMUREATING Date Receipt#
p z Applicant
'z 0 NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
U) become subjectm,he Worker's Cumpemmion Provisionsnfde labra Code,you must
a ]-' forthwith comply with such provisions or this Femur shall In,deemed revoked. BUILDING FEE In.
0. [� CONSTRUCTION LENDING AGENCY SEISMIC TEE
U z I hereby afmthan
firhcre iso eonnroction leading agency for the p affomunce of TOTAL: ELECTRIC FEE
O theworkforwhic i permltisissued(Sec.309],0v.CJ
Lenders Name ONB
OLenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) 1 certify that I have read this xppliwtlon and state that Nmove ove information is MECHANICAL FEE
�" W correct.IogreemrnmPly with nil city nnd county onliwnces end sum laws relating to PERMIT ISSUANCE
F•' y building construction.and hereby mutt representatives ofthiacity menterupont a I CONSTRUCTION TAX
Uz abate-mentioned property for inspection purposes. AU LTHR ORADDTOMECH.
(We)agree to save,indemnify and keep hmar ess the Ciry of Cupertino egeimt
liabilities,judgments,costs and expenses which may in any way acemeagainst said City AIR HANDUNG UNIT(170 10,"CPM)
incon he ting ofthis pnmik AIR HANDLING UNIT(OV ER 10."CFM)
E%HAUST HOOD(W/DUCI
Signature of Applicam/C ctor Date PAID
HEATING UNIT(TO 100,000 BTU) Date Receipt#
HAZARDOUS MATERIALS DISCLOSURE -
Wed by the Ca tit mo Mae buildicipal ng occupa pier 9e nr handle e Hath endazardous Safety
HEATING UNIT(OVER IW."BTU) T T
al
as defined by the 32pcnino Municipal Cade,Chapter 9.12,and the Health end Safety
Code,Senior 23532(x)1
❑Yes Sd Nm VENTILATION FAN(SINGLE NL•SIU)
-•N P I SVA CE DATE
WilUheappliceat or fumrebuildingmcuant mi
puseequipoemordevicawhichet BOILER-COMP(3HP OR 100,000 BTU) # [i'
hwardme,air contaminator,a defined by the Buy Area Air Quality Mdnagement BOILER-COMP(OVER 100,000 BT
IH
13RD Yes AN. NEW RESIDENTIAL.MECH. SQ.FT. APR
a-al�a• 5 1994
1 have read the hamrdous materials requirements under Chapter 6.95 of the CITY tar
Cif the uil ingfhados Safety Code,orse Sections 25505,25533 titisand M34.sponsi 1 understand that IaUYCN 1 IIV 1✓
the building does not current haves tenant,that it ismy responsibility a notify the
oc<upvn neo requi this ich muss be met prior to issuance of a Ccnific to of
Occupin Oft
Z.S �y
Owner orn drured agent Wm ISSUED(
OFFICE