25045 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11O11'B1RCRICAL PERMITNO. O
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
NUILIIING.PROJELf IDENTIFICATION
45
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI'ITAI.DATE
1 UNIT# LOT#
OWNERS NAME:!tZ - SI a 3zPHONE: CTOR'S NAME` LIC NO: NIC CONTROLp
- �'
• ARCHITECT/ENGINEER: LICNO: ADDRESS: ��' % ❑
I S_
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECTP MECH
PERMIT ISSUANCE 0 F-1UMB 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
WQXz I herchy affirm that l am licensed underomsisions ofaripter9( m
comencingwith
tFtd W 0 Section full force un)of l i,sam 333.ff the Busies and Professions Cade,and my licence is in PANELS /]/�. ��/�
FZUW I.icenu Clnss 'Lic.#�( UPTO2W AMPS 'g(/{/�
ret=y Dat Common �ftid 201-IOW AMPS
ZOriys"o HITECTS DEC ARATIO OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
oz-�
I untlerswnA y plans shall h used as public rccoNs. _ ® I 1
P ret SIGNS ELECTRICAL
Q`Y,4 Licensed Profcasi...I
ff < OWNER-BUILDER DECLARATION SPECIAL CIRNIT/MISC. � � ■
xOgF 1 hereby M.that 1 am exempt from the Contrxtor's License Law for the
m3gan following mason.(Section 7031.5,Business and Profession Cade:Any city or county TEMP.METER OR POLE INST.
L'J which requires a permit 0 construct,alter,improve,demolish,or repair any soucare
Y� micro,its issuance,also requites theapplicant for such permiuo file.signedsatement POWER DEVICES
that he is hem. ed moment to Neprovisions ofthe Contractor's Licenm Law(Chapter
qo�' 9(commencing with Section 7000)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC V ION
Ho, or that he is exempt therefrom and the basis for the alleged exemption.Any violationaf OUTLETS-SWITCHES-FIXTURES
FZ�- Section 7031.5 by any applicant for a permit subjects the applicant a a civil penalty of
G not
moratorium five hundred dollen($500).
� $ ❑ I,asownernfthepropeny,ormyemployeeswiNwagetmthe4soice.m enaauon, NEWRFSIDENDALELECIR _SQ,Ff. STORIES TYPE CONSTRUCT ION
e,3., will do Ncwons Code:
no Coreiactora License
La a dosnotapplyt an
and Professions Cale:The Contractor License Law does not apply m un owner of
property whobuilds orimpmves thcrcon,and whodom Hoch work hirnelforthmughhf, OCC.GROUT' RES.UNITS
emr,thees,pingor improvement
iss ld within one
earof ompleered for We.IL
however.Neavet a brimprovementithat withinoneyear or improve
for Nrpose of TOTAL:
builder will have the burden of proving that he did not build m improve for purpose of
e.).
❑ I,es awn<nffthe prvpery,nmeaclusively comructing with licensed contrectorsto QTY, PLUMBING PERMIT FEE FLOOD'LON APN
construct the project(Sec.7(M,Business and Profession Code)The Canlrecar's
License Lawdoes not app)yWaaownerofpropeny whobtuldaarimprovm thereon.and PERMIT ISSUANCE
whowmmelsforsuchprojeonwiNacontmctar(s)liuns puma ttothe Contmcwes ALTER-DRAIN&VENT-WATER LA
Licence law. (' ) FEE SUMMARY
❑ 1 am exempt on,Sm. ,B&P C for Nit reason BACK FLOW PROTECT.DEVICE OUTSIDE IT ES
SANITARY N
Owner Dau RECEIPf#
• WOR KMAN COMPENSATION DECLARATION DRAINS-PhOOR.ROOF,AREA,COND. SCHOOLTAX Y N
❑ IhercM1y affirm thetlbave.cenifiwte o(conum mxlLinsure,ora cenificam of RECEIPT#
Workers'Compensation Inmreprom a conifiudc FIXTURES-PER TRAP
copy Neteof(Sec.38W,Lab C.)which PARK FEE Y_N
covers all mnploy¢s under permit. 77 i GAS-EA.SYSTEM-I MC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION ZEES
❑
Company ro flay u GAS-EA.SYSTEM-OVER 4 EA) PIANCHECK PEE
Cenified
150Cerilied ropy is filed with the city ins ton division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action need not be completed ifthe permit is for..hundreddolhn(SIM) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is isaued.l shell WATER HFATER W/VENTIELELTR
not employ any person in may manner so as to become subject an the Workers PAID
Z Compensation awsof Califomia. Dau WATER SYSTENI/1'REATING Dam Receipt#
Applicant
Z 0 NOTICE TO APPLICANT.If,oflat making this Ceniftcateof Exemption.yo.should NEW RESIDENTIAL PLMB SQ.FT. TOTAL:
Pzi become subject to the Wmm(s C reprmationprovisiamof Ne Labor Code,you most
forthwith comply with such provision or this permit shall he dcemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SHISMIC FEE
Vz I hereby affirm that these is a construction[coding agency for the performance of
0 the work forwhich Nis permit is named IS..3W7,Civ.C.) qAI1I ELECTRIC FEE
Leader's Name
Q U Lender's Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
1 certify that 1 have peed this application and state that the above information is
correct.la mmrm I withal cit and finances and sate laws Matin to PERMIT ISSUANCE MECHANICAL FEE
grey pd he yen county g
U 7 hoove-mentmmod prop rr herchyaeNodm rerefer. tivesof Niscity to corer upon the CONSTRUCTION TAX
T,,,) 7 eMv(We)igred propeeYfor inspection pop tiara - ALTERORADDTOMECH.
tom- (We).grttntsave,indemnify and keep may in
Ne City of Cupertino against
liabilides,judgmrnts,costsandexpensm which may in any wayxerveagaimtuid City AI0.HANDLING UNIT(TO 10,000 CFM)
in quence of the gr ng of his permit.
x AIR HANDLING UNIT(OVER 10,000 CFM)
Sigmunr6F AppliwMCmunmor m EXHAUST HOOD(WIDUCf)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO 10F"BTU) Date Receipt#
Will the applicant or future building occupant store or handle ha oomour material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety IIEADNG UNIT(OVER 100.000 BTU) TO
Coda,Sermon 23532(0)7
EI Y. ❑No VENTILATION IAN(SINGLE RPSID)
Will thea licant orfututebuildin encu BOILER-COMP(3HP OR 100.00D BTU) ISSUANCE QA�E®
pp g panmueyuipmem ordevicm whichemit W
hamNom all commuri nuts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
• District?
1:1a 13MAY a 5 1993
YNo NEW RESIDENTIAL MECH. SQ.FT.
1 have read the wonders materials requirements under Chapter 6.95 of the
California Health&Safety Code.Sectiams 25505,25533 and 25534.1 understand Nat QI I I VI- yUrr n i DW
if the building dors not currentlyhave u tenantat this my responsibility to notify the
occupant
of the requirementswhich must Is,met prior to issuance of o Certificate of
Occupancy. [�\ /�p�/j1//��/
Owner or authorized agent Data TOTAL: ISSUER BY: V (.Jt R T