25767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO.
CITY OF CUPERTINO l'LUMtlING-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT 25767
", ;�Y•= oBUILDING PROaRT:'T,IUF.NTIPIGATION„c a x rc ;;' ' '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
a GE UNIT# - LOT# I1/I(Ca 3
O NERS NAME: PHONE: C #TRACTOR'S NAME: LIC NO:
A JNIC
C CONTROL#
•pRCHITECT/ENGINEER: I LIC NO: ADDRESS: -1
CONTACT: PHONE:
Q' ELECTRIC PER'MIT m > EbPEcE a i g,�
ILDING-PHRI' PO
�� �e�J`��W��•�r7 PLUMB MECH
(�1i\ �J�-� YER
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
MWz Ihereby affirm that l sm licensed underpravismas of Chapter9(commencing with
POO Section 7000)of Division 3 of the Basin.a it Professions Cade,and my license is in PANELS
d triple
and efrecr.
PQLicense Class Lieace" kLJ—T_ UP T0200 AMPS
Q 4 Dale Commemr 201-I000 AMPS
m SQ.FT.FLOOR AREA $/SQ.FT.
Fyyy ARCHITECTS OVER IWOAMPS
Z O mp I understand my plans shag be need as pante recoNa. 1 /� I" n
�yty SIGNS ELECTRICAL
�+�+� Licensed Pro(essinnal
OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
O W O 1 hereby affirm that I um exempt infinite, trect
Conote Licence Law for the - [vu/
WO 3 p vT following reason.(Section 7031.5,Businesa amfnd Pcasime Code:Any city or county TEMP.METER OR POLE MST. /^
a,
;For".
a permitto construct,alter,improve,demolish,or repair any structure it
prior".itsiasunce,also requires the applicant forsuch permit to file a signed statement POWER DEVICES DALE
y Os That he is licensed pursuant To tlm provisions of the Contractors License Law(Chapter
a pyoV. 9 with Section 7000 of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC I VALUATION
iC (commencing )
Way orthal he is exempfrherefrom and the basis for the alleged exemption.Anyviolationof C
1=�C Section 7031.5 by any applicant for apcmitsubjects the applicantm ecivil penalty of OUTLETB-$WITCHES-FIXTURES •� OZ oOC7
SG
net mom than five hundred dollars($500). NBWRESIDENTIALELECB _SQ.FPE
f. STORIES TYCONSTRUCTION
❑ I,asownerofthepop ty,ormyemployeeswiNwageeestheirsolecompenation,
a 3,., will Jo the work,and the structure is not intended or offered for sale(See.7044,Business
and Professions Code:The Convector's License Law does not apply to an owner of
property who bui Ids m improves thereon,and who does such work himsel f or through his own
employees, mvided thutsuch improvementserenotintemetoroffered fmsole.If, OCC GROUP BGS.UNITS
however,The buildingor improvement is sold within oneyear ofcompletion,theowner- T
builder will have the burden of proving that he did not build or improve Impious.of
#$d'#txxm-nx,s.;s—xi 7, x Xt% #
sale)I asowner.Tana m alt em exdusrvel vnnm with bcensed contract sto p k T}/,� t .PLUMBING PHRMITre �" # �-A$SPE& $.h FLt>pO ZONE APN
❑ P P Y. Ycon g r ' ;:'fr.aS sA.kY:b,r„+uovank� R ; A a6d4.a
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's PERMIT ISSUANCE
License Lawdoearm.pplytoanownerofproperty whobuilds orimprovesthereson,and
whoconvacts for such projects with artmeacior(s)licensed pursuant to the Convector's a"x-$,g aroa r
Licene Law. ALTER-DRAIN&VENT-WATER(EA) xi,. L b�PBH SUMMARY" ,7
C] 1 am exempt under Sec. ,B&PC for this reason E ME9
BACK FLOW PROTECT.DEVICE a ifl M SID
SANITARY Y N
Owner Date. DRAINS-FLOOR,ROOFAREA,CONE. RECEIPT#
WORKMAN COMPEN , ,SATION DECLARATION SCHOOL TAX Y—N-
1 hereb
Ihereby affirm that l have a certificate ofconsentto self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
WorkersCompensation lnsumncsora certified copy thereof(Sec.3800,Lab C.)which PARK FEE YN
ars all mpbyeeg undGe _perrplL
GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Poltcy#�( $-I —1'-C - BUILDING DTVI. NF889
CompanyaQ.xf T ruy GAS-EA.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ Certified copy ishereby famished.
-fa• Cedified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
//\\ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('this section need not be completed Him Ismailia for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
or hexad
I certify that in the performance of The work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so n to become subject to the Workers' - PAID
Compensation Lewsof Califomia. Date WATER SYSTEM/IREATING Dale Receipt#
0 z Applicant
Z
0 NOTICE TO APPLICANT:If,after making his Certificate of Mistrial.,yon should NEW RESIDENTIAL FILMS. SQ,FT. TOTAL:
T•+ Li) become subject in the Workers Compensation Provisions of the Labor Code,you must
tt^^ forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING ME I'
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herehy affirm that there is a construction lending agency for the performance of
U O TOTAL ELECTRIC HE
the work for whlp4 Chas In ec as Issued(S3f197,Civ.CJ
Lender s Name/>asFYs-5 f6:1trY A q }4 d b# *k 8#V'@## PLUMBING PEE
0 �F Landers Address - TY � MEQHANICAL CHRMIT6arc eat gxPEE°,4s
U I utility that 1 have read this ep,]Iran.and state that the above information as Yw;i,— ' '"3"-v,"=a v"s x#'#'#>F v n
correct.Ia agree m comply with all cit and count ordinances and state laws relmin to ` PERMITISSUANCE MECIIANICALFEE
8 Pdhe Y snr 8
U Z buildingconmuctiroertyfreb pectiaiu Ames.representatives of this city to enter opera the - CONSTRUCTION TAX
L) z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wt)some to save,indemnify and keep humorless the Cityof
eagaCuponsts again[
liabili[ies,juJgmems,cosh andexpens which rnyinany way accrue against said City AIR HANDLING UNIT(TO 10,000 CPM)
encs t, dngofthispermit.
/) AIR HANDLING UNIT(OVER 10,000 CPM)
Si con u EXHAUST H000(W/DUCT)
Signature of Applicant/ tractor Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
n defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Cade,Section 25532(x)? VENTILATION FAN(SINGLE RESID)
ID Yea ISSUAFCODATE10
Will the Mlicanterfuturebuildingoccupmtuseequipment ordeviceswhichemit BOILER-COMP SHP OR 100,00)BTU)
hazindoes air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) NOV 17 1993
District?
❑
Yes XNo NEW RESIDENTIAL MECH. SQ.PT. ���1
I have read the hazardous materials requirements under Chapter 6.95 of the - CQI Uf'W/'Cf{1IIVU
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand thai
if the building docs not menta y have a tenant,[het it is my responsibility to notify the
scup v of t meow which mull be noel prior to issunnoe of a Cenifiome of '
O u cy. b Q
Owner or mut ori .,an, ate TOTAL: ISSUED BY:
OFFICE