25101APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOth.1t,"loat - 1.111.1FRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECTMENTIPLJAI ION
PI7RMII NO.
25 0
J 1 1
BUILDING ADDRESS:-+
ZIP//V f, /�•A rte UNIT# LOT#
SANI'T'ARY NO,
AR'I.ICATIONSUBMIT'ALDAIF.
S
( NERS NA PHO�f!
1 C
CON CfOR"NAME: LIC NO:
N/C
❑
CONfROL#
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QT,Y: 8L'EGTRICIPPNMITr' *; + Ppg-
° S f 6" a r y I M' : tr " r
= BUILDING PERMIT INFO
BLDO ELECT P UMB MF.CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Thai 1 amlicensedunder provisionsofCbapler9 (commencing with
APPLIANCES -RESIDENTIAL
TOB UfSCRIPI'ION
PANELS
Seaionandaf Division Jofm<Business and Professions Code, and my license is in
fun force, and efrem.
lM1Ls'
I License Class Lic.#
UP T0200 AMPS
Date Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER IOOOAMPS
SQ. IT. FLOOR AR EA $/SQ. F3'.
SIGNS ELECTRICAL
Im
Licensed Professionnl
OWNER -BUILDER DECLARATION
Lew for the
I hereby uR m that 1 am exempt Tran the Cessions
n p
.SPECIAL CIRCUIT/MISC. / II n II
TEMP. METER OR POLE INST. /5 r -
_-
POWER DEVICES �(/�
Cs e: Any
t followwhich ng reason (Nation construct,
Business and improve,
di Professions Code: Any city or county
which requires a permit to construe, cher, improve, demolish, or repair any structure
suoment
sscensed,
`a..l' . Il.
V
of the Contractors
dow he ProtectprovisionsLicenseLaw (Chapter
hmhe is licensedptrsuumtoheproDisisisnf the Ge Basin lis License LshalsCde)
islor the the Business end. Any vote Code)
9 or that he is exempt Therefrom and basisof
Section 7131.5 by exemptmand the Permit
Section ]031.5 by my applicant for a permit subjects the applicant m a civil penalty of
subjects thedexemptt to civil
AI.UA ION
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTUR
Eve hndrdtry 'irs (S pl.NEW
RFSIDENTIALELECTR _SQ. FT.emfheprony,ormyemplhyecswimwegesasthe'vsalecampemauon,
STORIES
TYPF.CONSTRUCfION
;T10I.-
ssions Code: The Contactors License law does not apply to an owner of
who buil ds chimproves forest, and w h n docs such work himsel f or through his
own employees, provided that such improvements neenol infeadedoroffered foranle. If,
OCC. GROUPE11UN
however, the building or improvement is sold within ane year of completion, the owner-
will have the burden ofproving that he did not build or improve fa purpose ofsole.).
TOTAL:builder
"'
QT�;Y'�' PLUMBING PERMIT PEE
❑ I,nsownerofthepmpeny,amexclusivelycnmructingwiNlimnudwmmctonm
FLOOD ZONE
construct the Project (Sec. IIW4, Businers and Professions Code:) The Conamehowa
License Lawdoesnot apply to an ownerofnim shry whobuiIdsorimproveahereon, ted
PERMIT ISSUANCE
whoco orcu for such projects with occultations)licensed pulls ntwhecomrutors
License Law.
ALTER (EA)
e '
PEI. SUMMARY
❑ ltmexem mdcr c ,B& P C for this ream^
BACK PLOW PRO'fCCf. DI3VIC171
TSID, E:S
Owner On¢_
OtK OMP A ECLARATIOI
❑ Iherebyuffinothatlhuve ecM teaoofcnnuntmuif-insum,oraccelBcaoof
Workers Compenvtion Insurance or enifedcopythen f(Sm.380gtab CJwhich
covers tllemployees under this permit.
Policy #
DRAINS- FLUOR, ROOF, AREA, COND.
SANITARY Y N
REUe1PT#
SCHOOL TAX YN
RECEIPT#
FIXTURES - PER TRAP
PARK ITE. Y N
RECEIPfp
GAS - EA. SYSTEM -1 INC.40UTLE1'S ��
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (FA)
PLANCHECK FEE
❑ Ceiti9ed copy is hereby famished.
❑ Certified copy is fled with the city inspection division.
GRIASF./INDUSTRL WAST IT INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 20oFT.
ENERGY ITE
(This section need nm be completed ifthe permit is for one hundred dollars PI 100)
or less.)
WATER HEATER W/VEN'DELECIR
I cenifythat in foe performance of file work for which this permit is issued, l shall
not employ any Person n any answer so as to become subject to the Workers
Compensation Lawsof California. Date
Appllcwt
WA'TERSYSTEMITRFATING
PAID
Dme Receipt#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject o he Workors Countermand provisions of the Labor Code, you must
NEW RESIDENTIAL PLMfl. SQ. Ff.
TOTAL:
BUILDING PEE
forthwith comply with such provisions at this pemdt shell M downed revoked.
I
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that There is a construction lending agency for The performance of
ELECTRIC FEE
The work for which This permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
lei
i
QTY. °MECHANICAi.PIiRMITFEE?
' #
PLUMHING PEC
1 certify that I have rwd his application and sanction the above information is
PERMIT ISSUANCE
MECHANICAL FEE
correct, l agree to comply with all city and county ordinances and more laws relating in
building construction, and hereby auhm;u represemmivea of hisciry theater upon the
above-mentioned propMy for inspection purpoua.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
We) agree to save, indemnify and keep hawleas me City of Cupertino against
IiubiI tiu,joil cuts, costs and expenses which may i90Y way accrue against said City
AIR I IANDLING UNIT(TO I0k000 CFM)
inewas hen IM1e min ofill ispermit (.114-43
AIR HANDLING UNIT (OVER 111,000 CPM)
alum of pplicw mmctt Dare
EXHAUST HOOD(W/DUCT)
PAID
HGTING UNIT (TO 100,000 BTU)
,r
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building creoprm emu or handle fluctuations material
as definedpe
by the Cupertino Municipal Code, Chapter 9.12. and The Healh and safety
HEATING UNIT (OVER IW,11(I(1 BTU)
1' L:
Cede, Section 25532m)? 5ox ❑ No
VENTILATION FAN (SINGLE RHSID)
Will that liwmnrfmure huildin
pp goccupam uxeyuipmcnmrdeviou whichemit
BOILER -COMP(311POR 100,000 BTU)
ISSUANCE DATE
BOILER - COW (OVER TIN M BTU)
hamNous air conuminanu u defined by the Bay Area Air Quality Management
Districts 11P
❑Yes No
A 1 D
NEW RESIDENTIAL MECfI. SQ. IT.
1 have read the hvnrdom materials requirements under Chapter 6.95 of the
if the uil Ing dM1 & Safety Cate, Sections 25505.25533 and 25534.1 underhand that
itismyresponsibilityIli the
ifthebuildingdoesnutcuremlyhaveust
MAY 191993
enotify
heet
n'Imum of the rcynimmcnb which must be met prim m issuance of a Certificate of
Occnpuncy.
C1 f1 3
ISSUED BY:
Owaswin i umiriexi agent Data
TOTAL:
tJrr0..r