25164 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION 1 -ELECTRICAL PERMIT NO. 25164.
BUILDING YOFC D ERTI APPLICATION/PERMIT PLUMBING-MECHANICAL
DUILDING PROIECI'IDENTIFICATION
BUIIAAY ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATU
• uo z- UNIT# LOT'# 3
#LOW414ERS NAMf?: L PHONEa CONTRACTOR:ti NAMB: I.I N :014 M99R94j,_ /+.f/ECT/ENGI LIC NO: ADDRESS: �� ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE ,`Q BO EL
TRvici
PLUMB MOH
LICENSED CONACTOR'S DECLARATION pppLIANCES-RPSIDENT'IAL V
pC7, IImebya(firm don l am liccruW underpmvi,ionsofChap,,9(c.mvingwiN JOB DESCRIPTION00 Section 7")o'Division 3 ofthe Business and Profession Code,and my license is in PANELS
T t E full force and effect. Q_1 ��'�I_2 �'/' -
GPF R! Dalef.QJ@3�J�L Conor UP TO]OO AMPS E ec
Do' D�'19 Commcmr s' M ]01-IOW AMPS -(-•.�� lam•
�N ARCHITECTS DECLARATION OVER10110AMPS FT.FLOOR AREA S/SQ.FT.
{y. 1 understand my plana shall be used ss public records.
<g L¢eneM Hofeavaal SIGNS ELECTRICAL
Si w OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. "iD
0 I hereby affirm Nat 1 em exempt from the Cim ucwrs License Law forirern following reason,(Sectian]OJ LS,Business foal Professions Cade:Any city or county TEMP.METER OR POLB INST.which requires u permit to conswct,slier,improve,demolish.or name any swctum
�;!la� prior to its issuance,ales requires theapplicaut fmsuch pemtiuo file.signed cuimnem POWER DEVICES
i`ate 0 0 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter DATE
e,t 9(Commencing with Section]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA
_rn or flm he is exempnhercfusumd the basis fon he alleged exenptiun.Any viohdamof SWITCHES I. Section]031.5 by any applicant for a permit sub ects the a Iced 10 a civil OUTLETS- FI%TURPS
C, 0
t nose Nan five hundred do[).($50d.
j �� Penalty of .0
W C, m
❑ I,mownerofNeproperty,urmyemployeeswifawagesssfacirsolecompensu0on, NEWIt"'DENTIALELECTR _SQ.PT. STORIES TYPE CONSTRUCTION
will do the work,and thestrucre isnot imenoro
dedffered forsale(Sec.]044,Business
and ProfeWrous Code:The Contractor's License Law does not apply to an owner of
ownemwyces. ovidi proveafaempmve mmamnsuchworkoroffeafaru[e.If.s
veneer,the
nam imemdedmpletimd theow. r- OCC.GROUP RES.UNITS
however,faebuildingorinprovaantissoldwithinoneyear, or improve
purpose f _B
builder will have the burden of proving fact he did not build or improve for purpose Of TOTAL:
❑ I,mowarnfffic any,amexclusivelycmvactingwithlicensWconvactonw QTY.'' PLUMBING PERMIT FEE FLOODZONE APN
construct the pnject(Sec.7014,Business and Professions Code:)The Contractors
License Luwdoesnotapplynunownerofprop Mwhobuildsorimprovesthereon,and PERMIT ISSUANCE
whocontracts forsuchprojeca with acontrachins)licensed Initiation to the Comanum's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
I] I nm exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE:
0ownerDateSANITARY Y N DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTN
harebWORKMAN COMPEmmid'eNDECLARATION SCHOOLTAX Y_N_
❑ era Co affirmfaatlhevm ttracadeofcansennreof(Sce.31 Ora abC.)weM FIXTURES-PER TRAP RECEIPT#
Workers'employees mudr,u his peracenified copy Hereof(Sec.3gW,LabCJwhich PARK FEC Y N_
covers ell employee's undenhis permit. GAS-EA.SYSTEM.1 INC.4 OUTLETS
Polity p RECEIPT#BUILDING DIVISION FEES
❑
Cl CenrapifiM copy is hereby famished. GAS-PA.SYSTEM-OVEt4HEA) PLANCl/ECK FEE
❑ Certified copy is filed with the city inspection division. GREASPJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP =PTIF,
COMPENSATION INSURANCE
(TNs section need not be completed ifthe permit is for one hundred dallan(SIW) SEWER-SANITARY-STORMEA,3WFT.
or lass.)
I certify that in the performed"ofthe work for which this permit is issued,)shall WATPR HEATER WNENT/P.LECIR
of employ any person m an mama o a m ta m y 'eet w Ne Workers'
z
compensation ogCali t m WATER SYSTEM/1'RLATING ReceiptM
Q O Applicant
NOTICET PP CN" IL daring this Certificate of Exemption.you should NEW RESIDENTIAL PLMIL SQ.FI'. TOTAL:
y become jecI to the Wo ares Compensation Provisions of the Labor Code,you must
foMwi comply with such provisions or permit shall be deemed revoked. BUILDING
Q CONSTRUCTION LENDING AGENCY SEISMIC ITH
z 1 hereby affirm fast them is o construction leading agency for the performance of .a Q
U O the work for which this permit is issued(Sec.3
n9T,Civ.C.) TOTAL: ELECTRIC FF.E
CI. P Lenders Nana
p Lender's Address Q'fY. MECHANICAL PERMIT : FEE PLUMBING FEE
U I certify that I have read this application sod atom that the above information is
F6i correct.l agree to comply with ell city and county adjusters,and suite lows relating w PERMIT ISSUANCE MECIiANICAL FEE
rA buildingconstrucpion,and hereby mahouts,represenwtivesoffhiseiy wenterupen the
U above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH, CONSTRUCTION TAX
(We)agree w save,indemnify and keep harmless the City of Cupertino against
Iinbilitiu,judgmenB,c an n. swhlchrmyin any ay accmeegdnst said City AIR HANDLING UNIT(TO IO,OOp CFM)
into uenee of Ne of - Morris.
AIR HANDLING ER G UNIT(OVILETEN CFM7
wrc
IgneofA on
an vactOr 'Date EXHAUST HOOD(W/OUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(M IN,000 BTU) Date ReceiptIf
Will the applicant or future building occupant store or handle hazardous materiel
m HEATING UNIT(OVER 100,000 BTU) TOTAL:
defined by the CuPenino Municipal Code,Chapand ter 9.12. the Health and Safety
Cade,Section 355]4(00? ��//
❑Yes VIN. VENTILATION FAN(SINGLE RESID)
Willfa1,em canmver,.building by the
museeyuiDmir Quality anagerwhichicmit
BOILER-COMP(3HP OR IN,"BTU) ISSUANCE DATE
huntrict? air cmnaminanu m defined by the eq Ara Air Quality Management BOILER-COMP(OVER 100,00)BTU)
District?
❑Yea Na P A 1 D
NEW RESIDENTIAL MECH. SQ.FT.
1 have rend he Ina,Safety
C ahs nations requiw5533 order Chapter 6.95 of the he JUN 0 7 1993
California a,do&Safety Cade,have
ha25505,35533 and 25534.1 understand that
if the building does oat cu or have a s'be that it is my rsuance of a er unify of
atop t he rcyuir m tie un be met p' r m issuance of a Certificate of
acoafmr Cil) Vf VUI'C1111h1V
O ere or amhoriz agrnt Date TOTAL: ISSUED BY:
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