28103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO1 1 1 .-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n O 1 O
ISUII,UING DIVISION 11EILDING PROJECT IDEN'I'IFICA'I'ION L o 1
BUILDING ADDRESS: SANITARY NO. APCLICA'IION SUBMITTAL DAIT:
O S Ah1C: PHO �� ��
CONTRACI'OR'SN , • IACNO:
NIC CONTROL#
.RC1 TEC'/EN(ANEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INEO
QTY. ELECTRIC PERMIT FEE
L APLUMB MECH
PERMIT ISSUANCE 1:1 El
CENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �1- 'Jrk'r�/Fo��ccww�e/Iv
eeiz Iforml afirssahm lamlicemed unJcr Wovisinns of Chapmr9(commenting wish %��A '\`�_\V��
�L300 Section 701 of Division 3sf the Business and Professions Grade,and my license is in PANELS V•+ �//�/��]�J�F�p''l/��
QUF f
ll uo
fulasseffecl.
F-ZLL
full
use UPT02WAMM
Class Lic.p
",<c. Date Contractor 201-IOW AMPS SQ.17,FLOOR AREA EISG�FT.
F,z ARCHITEC'T'S DECLARATION OVER 1000 AMPS
z O a, I understand my plaux shall be used as public records.
Oz_❑
L co SIGNS ELECTRICAL
Licensed Pmfessionnl
dj�)y K6
OWNER-0111LDER DECLARATION SPECIAL CIRCUPI/MISC.
XOit.U 1 hemby affirm that I em exempt from the Cormicmr's License I.aw for the
following reams.(Section 7031.5.Business and Professions Cade:Any city or roomy TEMP.METIiR OR POLE INST.
which requires a permit to conaruct.alter,improve,demolish.or repair any stmemre
f tr�{rlIY�
prior in issuane
c ,also requires thenpplicaut forxuch permit file a signed statement POWER DEVICES
rt
aC<0 Thal Joe is licensed...... rate provisions u[the Contractor's License Law(CM1apmr
W S 00 SWIMMING POOL ELECI RIC
as.XCce ce 9(commencing with Section'10YE.I'Division Sof the Business unit Professions Code)
n. _VALUATION
X an he is exempt tcrefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%Tl1RLS
tKL w
Section 7031.5 by any applicant for a Permit bjects the api icant to a civil penalty of
nal mom limn five hundred dollms($500).
�-O NEW RESIDENTIAL 131.IiCIH _SQ.IT. S'IDRIFS 'I'VI'G CONS'IRUC110N
_0 ❑ oche wrk.ran thespun%armyemtendedswithwegesastcste.compensation,
a3=e will dotewono Code:
The Cure isnot intended Law ffierecl
apply to an Business
and Professions Codm The Contractor's License Law docs not apply m an owner of
progeny who bei Ids or improves theram,and who docs such work himsel f or through his
OCC.GROUP RES UNITS
own employees.Provided that such improvements are not intandedoroffefcd instate.If,
however,the building,.,improvement is sold within one yearof complaion.de owner
builder will have the burden of proving that he did not build ar improve for purpose of
sole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ 1,asown<rnnhe pmpcny.am exclusively contracting with licensed eontractorsto
nswct the project(Ser,711 Business and Professions Code:)The Contractor's
License lawdPex not applym anowncrofpropeny whobuildsorimpmves thereon.and PERMITISSUANCE
win<anlrcm for such projects with acommcmr(x)licensed goon om to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l am exempt undo Sec. .B&P C for this reason BACK FLOW PROTECT'.DEVICE SANITARY
19:hS
Owner Dam SANITARY Y N
DRAINS-FLOOR,ROOF,AREA.COND. RECEIP'N
WOR KMAN COMPI3NSAT[ON DECLARAI"]ON SCHOOL TAX Y-N-
0 I hereby affmmm that l have sermifcam ofconscmt mselLlnanre,ora certificate of FIXTURES.PER TRAP RECEIVE of
Workers'Compensation lnsufsmrce or a cenified<opy tereof(Sec.3g W,l,ah C.)which PARK FEE Y N
^ rall emP Yee's andhpcnnL GAS SYSTEM-1 INC.INC40UTLITS RECEIPT%
policy is BUILDING DIVISION
FLLS
Company GAS-E.SYSTINTOVER 4(EA) PI ANCHECK FEE
❑ CcnifiM copy usticreby fumishal.
❑ Comosd copy is Bled wit the city inspection division. ORESFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF:EXEMPT'[ON FROM WORKERS' GREASE'IRAI' SOli's FrE
COMPENSATION INSURANCE
(This section aced not be completed dfthe .if is formic hundred dollats(SIM) SEWER-SANITARY-STORM E.201 INERGY FEE
or less.)
I ecolfytbatin thegaborance.1 the work far which this permit Ts issued,l shall WATER HEA'TCR W/VENT/ELEC1'R
nm employ any perm. in any manner so as m h<om,subject m the Workers' PAID
Z
Compensationlawsof Califomia, Date WATER SYSTEMTRFATING Dam Receipt#
zApplicaut
z NO'T,'ICGTO APPLICANT:If,nI¢r making this Certificate nl Exemption,,You should NEW RESIDENTIAL PLMB. SQ.F1'. "I OTAL:
C,) abo
) become subject to the Workers Compensation provisions of the Labor Code,you muss BUILDING PCE
W 7 Lonhwith comply with such provisions or this Permit shalleem
be ded mvokO.
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affimt that mere is a construction lending agency for the performance of
V to work for which this permit is ismod(Sec.3091.Civ.C.) FAL: ELECTRIC 193E
Lender's Name PLUMBING FEE
U" F Lender's Atlanta, QTY. MECHANICAL PE
L1 1 ceridy that 1 have read this application unit state tat the above information Is MECHANICAL FEE
>" comet.I agree tocomply with all city said county orAireat and state laws relating to PERMIT ISSUANCE
h' pj
,no
mesion oulmiz pmxenmlivesoflhiscily m enter upon the CONSIRUC IONTAX
V -mcntianed Pro anty for ins ci rsex, ALTER OR ADD TO MI3CH.
at agr Indrou and p rmlass the Cimy n[Cupunino eguinxt
e s .d tenor inanywaysi
ecrm...nstsaid City AIR HANDLING UNI'F(TO I QIXXI CFM)
;t,,
o he lin[o s cfmi
n AIR HANDLING UNIT(OVER 10 DEC CFMI
tgnaw dApgli<anUCnmm ns Date( EXHAUST HOOD(W/DUCE)
PAID
HAZARDOUS MATERIALS DISCLOSURE IfETING UNIT(TO 1010,030 BTU) Date Receipt X
Will the applicant or future building occupant store or handle hamobs s material
is Jelled by the C.,.in.Municipal Cade,Chapter 9.12,and the l leahh and Safety I MATING UNIT(OV ER 100,000 BTU) 'IGTAI-:
Cade,Seem. VENTILATION FAN(SINGLE BESIDE
❑Yes ❑No
BOILER-COMP CEIP OR 100,000 BID) ISSJ'{�A[�,CE DATE
Will lhit ourmnmorfumrc builiried by he Bay Am.Air Quality
Mor ichamit s{�� e O
evaoux air contaminants u defined by to Bay Ara Air Quality Management BOILER-COMP(OVER I010.000 BTU) '•!/f�
a Distrin^ II�y
❑Ycs ❑No NEW RESIDENTIAL.MCCII. SQ.IT.
SII 1 have read to hvard.us materials requirements under Chapter 6.95 of the C/ry G/:'�U 1996
Califomia Health&Safely Code,Sections 25505,25533 and 25534. 1 understand tat f)
if the building docs not currently have a tenant,that it is my responsibility to notify the
acupant 01 the mquirsmtems which must Former prior to issuance of a Cenificam of
Occupancy.
Owner or uulherized agent Data TOTAL: ISSUED BY:
OFFICE
'95-05-12 13:50 ELWELL TRUCKING , J, 1 „J �Irya.�r/N P.2
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AQP fAU C-U;W '
MAY 171995
BLDG; INSPECTION p
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