25794 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB LU] .-LL MC I.WAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-.\IECHAn'ICAL n C '7 ['1 A
-BUILDING PROJECT IDENTIFICATION L J 1 9 4
BUIL22DING AUDRIiSS: D �� tiANITARY NO. AI'PLICA'IION SUBMI"PGLDA"I
UNIT# LOT# LZZ/G13
J"�WNER. Gn 1'� 0 PHONE: CONTRACTOR'S NAME LICNO: NIC ll CONTROL#
too ass to a
•iCHITECl'/ENGINEER: LICNO: ADDRESS:
I
'CONTACT: PHONEPERMIT INFO:""%'e'
QTY. ��.' ELECTRIC PERMFf';^ . FEE BUILDING
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
CCZ I hereby,affirm mhalam lieenud unJerpmvisionsnfCTap¢r9(commencing wnM1 10B DESCRIPTION
X00 Section
rceandnfetDivision3of the BusinnsanJ Rafcssiuns Cale.and my license is in PANELS
y'- full farce and-fifes.
¢L� License Class Lic.# UP TO 200 AMPS
,<r Dae Co..,c or 201-["AMPS
C SQ.FT.FLOOR AREA $/SQ.FT.
I—uhZ ARCIIITIiLTS DECLARATION OVER IWU AMPS
P,-Om Imode..landmyplensshall be used a,public reimol,
'L C
F u SIGNS ELECTRICAL
zxr Licensed Profcssiowl OWNER-BUILDER DECLARATION SPECIALCIRCUITAIISC.
Oa0 1 hereby air,.now 1 an exempt from rhe Contractors License law for the
ami S u.y following reason.(Section 7031.5.Business and professions Code:Any city or county TEMP.METER OR POLE INST.
C't, which requires a permit to comvuct.alter,improve,demolish,or repair any structure
"W to it issuance.also hon licam fw.uch .it file a%inedsmtemrnt POWER DEVICES
pour requim%r pP pemhi 6
v,aznO that he is licensed Ourswnuothe provriona of the Contrwmr's Li¢nse Law(Chapter SWIMMING POOL ELECTRIC
=�nY 9(commencing with Section 70(1 of Division 3 ofthe Business and Professions Coda l r VAI}�41 ON1
y or that he is exempt therefrom and rhe basis for the alleged exemption.Any violudonaf ✓ j
� Sri ]031.5 by any applicant for apermitsubjecu the a i,fcam 1.acivil penalty of OUTLETS-SWITCHES-FIXTURES /
re than five hundred dollars(8500).
—C NEW RESIDENTIAL ELECTR _SQ.FT. IE STORMS TYPE CDNSTRUCTIO)
�_m usowncrof Ncprapeny,armycmployceswith wagesmtheirsalecompcnsaean,
e3 willdo work.and the structure is not nnendedoroffered mrsale(Sec.]II4e,Business --and Professions Cade:The Contractor's License law Jens not apply to em owner of
property whobuilds orimproves lhertvn.aM whodhxs xuchwork Nmselfar Mough his
own
employees,provided lhause uch improvements anot intendcdcroffemd forsale.If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yew of completion,the owner- TOTAL:
bas ldcr will have the burden of proving that he did not build or improve for pwpo.c of
i
sO)i.mownerofthe n QTY 5 + tis PLUMBWG PERMIT tYl )I R;FEEt2f FLOOD ZONE ANN
pmPe Y•ameadus velY convaci ng with licensed convactom 'h•,i
construct the project(Sec.90aa.Business and Professions Code:)The Controcmrs h.
License lawdoes not applymanownero(property who buil4 orimpmves Neuron.and r PERMIT ISSUANCE
whocanvwts for such projects witbaconmucor(s)licensed pursuant to the Contractors ALTER.DRAIN&VENT-WAI'ER(EA) _ � ,: `.!..FEESUMMARY Ix-±- k' ,'
License Law. Y
I 1
❑ I am exemPL under Scc. .B&PC for this reason BACK FLOW PROTEDCV ICE t c OUTSIDE
CT. ES
SANITARY Y N
Owner Da¢ DRAINS-FLOOR.HUGE.AREA,COED. RECEIPT0
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm that l have a certificate ofecttscnl to self-insure.or a certificate of FIXITIRFS-PER TRAP RECEIPT#
WorkersCompensation Insurance or Acenified copy thercof(Sec.3800.Wb C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I WC.i OUTLETS RECEIPT a
BUILDING DIVISION FEES
Policy M
Company GAS-EA.SYSTEM-OVER a(EA) PLANCHECK FEE
❑ Certified copy is hereby furbished.
❑ Certified copy is filed with the city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This000lmnnced mtbeorm,drmd ifthepermit is firanchaodreddallws(SIM) SEWER-SANITARY-STORM EA.2oUFT. ENERGY FEE
or less)
I cenifythut in the pedominance afthe work for which this pemhi,is issuW.Ishall WATER HEATER W/VENT/ELECTR
not employ any person in anymarmer so as to become subject to the WorknY RAID
Compenutian Lawsof Calimrma. Dae WATER SYSTEAI/1RFATING Data Reccip,N
Q ZApplicant NEW RESIDENTIAL PLATE. SQ.FT. TOTAL:
Z NOTICE TO APPLICANT:If,after making this Cemficate of Exemption,you should
(n become mbject to the Warker%Compensation provisions ofthe Labor Code.you must
7 fonhwith comply with such provisions or this permilshall he deemed revoked. BUILDING IEE
S Q
CONSTRUCTION LENDING AGENCY I SEISMIC FEE
Z 1 hereby affirm tha then is a construction lending agency for the Performance of 1
TO ELECTRIC IEE
V m
the work for which this pernu ...ed(Scc 309].Civ C.)
Lenders Name a' 'w w.ry axu' p.- r.^ �. [ Y+• rc;
Yll l} PLUMBING FEE
Lender s Address QTY "- '` nMECHANICALPERMIT,`�, N,# '�IPEEz,
0 V 1«nif that 1 have read Ih s indication amid sou that the above information tu_'1('Stc o-•. _ # <..
Y PP MECHANICAL FEE
so r. lagrtt to comply with all city and-Dory ordinances;and suite laws rclaingm PERMIT ISSUANCE
I'^ buddingcmla, -tion.and hereby authorize represermives offloscity to enter upon the CONSTRUCTION TAX
U Z ebuve-nnern. d property Elmspection phaposes. ALTER OR ADD TO MECII.
(We)of cc to save,in randy and keep haime,'s the City of Cupenino against
liabokic, jut gmems.masexpmeswhichmayinunywaya coaeagainstsaldCity AIR HANDLING UNIT(TO 10,000CFM)
in can- nftIx,,mo g fthapennit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Sigrm rtof ApplicanUCunvanor Date EXHAUST HOOD(W/DUCD AVD
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dae Receipt n
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IW,(NI)BTU) TOTAL
as JefineJ M1y the Cupertino Municipal Csde.Chapur 9.12,and the Ileallh and Safety
Cod,Sermon 25532(a)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE DATE
WilUhanppliwntnrfuwmbuilJing hhecupwtu.eeyuipmemnr Jeviceawhichemit BOILER COMP CHP OR 100.13lO BTU)
mardou%air comumirarv,as defined by the Bay Arca Air Quality Management BOILER-COME(OVER IW,IM BTU)
District2 I^y y
❑Yes ❑No NEW RESIDBN IAL MECH. SQ.PT. C
I Live read the hazwdaus materials reyuircmams under Chapter 6.95 of the !p� U
C+lifamSc
ia Health Cala,Sections 25505.25533 and 2553x. lundersund that NOV 22 1993
IE the building does not currently have a tenant.That it is my responsibility In notify the
'spam of the requirement.which must be met prior In issuance of a Ce,u icwe of
O'r."ney. �,,, Y
Owner or authmimd agent Date TOTAL: ISSUED DY:
OFFICE