26153 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DILDIN°-RC111111 c^ PERMIT NO.
APPLICATION/PERMIT PLUMB NG-MECHANICAL n[k aI C
BUILDING DIVISION RU1LDING PROJECT'IDENTIFICATION L v 1 J
ISUII.DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWOI 2�aI J C( Vl/k��T U t� UNITp rp¢5��/rypp UL,, LOTH
W de ?: IC NO h
V 2.5 ✓FST l.J� CONTj/ //� COO �IF.u � N/C CONTROL
�A CTH Ef7 ENGINEER: LIC NO: ADDRESS:
a.D48 Arro•.,oz./ Cru�T �tIS�3 � ❑
CONTACT: Pxorve: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMITISSUANCH ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL G�4M JOBD CRUPION
pKZ I hereby affirm that l amlicensed untierpmvisionsofChapmr9(comunencingwiN O
P400I=. Section 700)),f Di " 3ofdw Ba'nessand Profession Code,andmylicerue isin PANELS
ty UU fullforeandeffectvtsmn C- Do s //
Fza I.i«mac claaa Li,
.N wTQ Zoo AMPS &45 Ws,/ -er Heti-)'ey,
ut<� Dare Contractor 201-1000 AMPS
'L[vsz ARCHITECTS DECLARATION OVER 100o AMPS SQ.FT.FLOOR AREA $/SQ.IIT.
01—0 1 undcmm�A my plans shall be used as public records.
CI—W SIGNS ELECTRICAL
—,�gj Licensed Professional
os< OWNER BUILDER DECLARATION SPECIAL CIRCUTOMISC.
XI hereby off.the,I rm exempt from the Conlracmea License Law for the
W :t following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�Vt o 4 xc whirh ompmres a permit to construct,moor,improve.demolish,or at any stmchore
prior to itsissuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
C O that he is licensed purauam to the provisions of the Contractors License Law(Chapter
4•Xp� 9(nmrnmuencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'ITON
yt_y or the,he is exempt therefrom and the basis for the alleged exemption.Any violation of
F Z¢ Section]031.5 by any applicant for a permit s.b,..the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
f S not more dom five hundred dollars($500). NEW RESIDENTIAL ELECB .
�(=o ❑ I,asowneroflhepropeny,ormyempinyeeswithwagesastheirmlecomperss.tion, 5 Q FT. STORIES O TYIECONSTRUCf10N
a3- willdo the work,and the suumum is not intended proffered for sme(Sec.]OM,Business f�
and Professions Code:The Contractor's License Law does not apply to an owner of
propcny,whobuildam improves themon,and whodoessuch work himsclfor through his
hoemployees,providedthat such improvementsersnot insendcdoroffevd forsele.If. 1 G U RES.UNITS
wever,the building or improvement is sold within one year ofeempledum.the owner- V i,
builder will have the burden of that he did not build or improve far f TOTAL:
proving p puryoseo
mc.). qFFG
❑ l.mer he project
(Sm.7044.m Business
tingwProfession,
Cardee)n Contractor's
QTY. PLUMBING PERMIT D E F qpN
ice met the project(Sec..ans.Business and Professions Code:)The Contractor's
Licensetrawdfor such
whoed!puouarm vies Commu,and PERMIT ISSUANCE
wharon L.w.forsuch projects wilhaconvactor(s)Iicensrd pursuant tothe Contractors ALTER FEE SUMMARY
Liccrse Law. (G)
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UTSUDE ES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIFrx
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihercby affmnhat l have a certificate,ofionsentto self-imeare,or a certi0cam of FIXTURES-PER TRAP RF.CEIPip
Worken'Cnmpcnsation Insurance or nncrtifed copy thereof(Sm.JSOO.Lim CJ which PARK FEE YN
covers all amp tbia� tIA GAS-EA.SYSTEM-]INC.40UTLE1'S RECRIPTM
Policy k tl d� BUILDING DIVISION FEES
Company s
❑ Certified copy is hereby fumishe. GAS-G.SYSTEM-OVER 4(EA) PLANCHECK REE
$ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not No completod if Ne permit is forone hundred dollars($1110) SEWER-SANITARY-STORM EA.200FT, ENERGY TEE
or less.)
I certify that in the perfo.m.ftha work for which this permit is issued,Ishill WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
z Compensation Lawsnf California. Date WATER SYSTEMiT EATING Da Receipt If
Applicant
z C) No OCR TO APPLICANT:If.after making this Curifiwm of Exemption,you should NEW RESIDE? IAL PLMIL SQ.FT. 'TOTAL:
f— QO become subject to the Worker's Compens.don Provisions ofthe Labor Cods,you must
forthwith comply with such Provisions or this Former shell M deemed revoked. BUILDINGFEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that Them iso construction lending agency for the perfomanee of
U O the work for which this permit is issued(Sm.3097.Civ.C.) TOTAL: ELECTRIC IEE
fender's Name
O U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and state that Ne above information is
correct. l some to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
F" buildingconstmaion,and hereby eathnriu represemativex of this city memmaponthe
U z shave-mentioned property for inspection purposes. ALTER OR ADDTO MECIL CONSTRUCTION TAX
(we)agree to save,indemnify and keep harmless the City of Cupertino against
iabilitics,jultmems,costs andexpenses which may in any way sooner gam.said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of the gmnling of this permit.
AIR HANDLING UNIT(OVER 10,0)0 CFM)
Signature of Applieant/Conuactur Dam EXHAUST I IOOD(WMUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Rwciptx
Will the applicum or forum building occupant store or handle hewdous material 1
as(formed by the Cupertino Municipal Cdr,.Chapter 9.12,and the llemth end Safety HEATING UNIT(OVER 100.000 BTU) TOTAL: l Code,Section Yes x)?,�5
❑Yes RTY VENTILATION FAN(SINGLE RESID)
BOILER-COMP CHIP OR 100,000 BTU) ISISU u Nd DATE
Will the applicanmrfmurcbuildingcecupanluxequipmem ordevices which emit A u ��11
havurdoov air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,x0 BTU)
Di.'inal ./ IM�(I q/C (J((��
❑Ycs No NEWRESIDGNTIALMECH.—SQ Fl. MAY 25 19s�4
I have read the haaard are materiels requirements under Chapter 6.95 of the
C.I,fornialleallh&Safety CWd.Secti.n,25505,25533.d25534. lundoodandthm CITY
I'I'PEHI
if te
the building dors not currently have anant.that it ismy responsibility to notify the VII •r W
Or I mu
of the re cnu whim mast No met prior to issuance of a Cenificne of
Owner or auNnnud agent D:ne
TOTAL: ISSUrD BY:
OFFICE