25810 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILUI .-H.LM. NI AI. PERMITNO. c 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 5810
BUILDING PR(1JEC'T IDKN'1'IPICATHIN
. BUILDWUADDRIiSS: /T SANITARY NO. APPLICATIONSUBMIITTALDATE
// G-/ UNIT# LOT 1V!V1-i
OWNI' SNAME. PHONE: CENTRA OR'SN E: LIC NO: N/C CONNTROL#
6 �e 3
RCHI :CT/EN EER: LIC NO: ADDRESS: ❑
t�7 Gi h r—
ONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELIiCIPLUMB MECH
PERMIT ISSUANCE 1< 11 o
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL yi0 SCRIPTI
Z"z I hereby affirm that l am licensed underprovisions of Chapmr9(commencing with Q
1+100 Section 70(N)of Division 3 ofthe Business and Professions Cole,and my license is in PANELS G1 �d
yFF V fall farce ane efree yf �c S �+
a [[[u❑❑❑���' License CJuvs Lic.# G UP 7020 AMPS r !
FF. e Dale-�:�= Conuvo 201-Rod AMPS �G /
ZFNZ, ARCHITECTS DES OE ARATION G OVER 1000 AMPS SQ.I'I'.PL BARBA $/SQ.IT
OZ-0Ow 1 understand my plans shall be used ss public records.
~co�.J SIGNS ELECTRICAL
Q,j '] Licensed Pmfaeionel
Wy.WQOWNER-BUILDER DECLARATION SPECLV.CIRCUIT/MISC.
XOiV I hereby affirm that 1 sm exempt flan toe Communes License Lew,for the L—il
W 3 W c, following motion,(Section 7031.5.Business and professionals Cade:Any city areaway TEMP.METER OR POLE INST.
I=umotion,y05 which¢quina a permit m ronafact,Wma improve,demolish,or repair any wromme
>7, prior wits issuance.elsorequires the applicant foraauu
such peniuo Ble asignedment POWER DEVICES
W Y p0m that he is licenced purauanno the provisions ofthe Contractors License Lew(Chapter
n.doLL 9(mmmencing with Section7000)of Division3ofthe Bminessand Profeerians Code) SWIMMING POOL ELECTRIC VALUATION
p•.,y
.,,hot he isexcmpuherefmm and the basis for rhe alleged exemption.Any violation of OUTLETS
-SWITCHES-FI%TURES
IZZQ Section 7031.5 by any applicator for a permit subjects Ne applicant toacivilpenaltyof
��❑
r mom than rofthe roNrtyllarmyem). NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCGON
C o n❑ Lmownernfthepropedy,orm of ancryeeswitbwagaastheisole(Sec. 0,14,8 Business
and
y3°0 will do Prthework,Code:The Comermases License
offiered wdoesacta Sec.7044,Business —
and Professions Code:The Qmt ere.s License Law does not apply to an owner of
iintensityovorwwho...Ws nrimpmves thereon,and who doessuch work M1imeelfonhmughhis i UNI
ownemployeos,p building
or
rimprve impmvementhinne intendedorplerma.forsale.If, i.
however,the huildintl orimprovemem is sold within one yearofcompletion,rbc owner TOTAL: ��
builder will have the burden of proving done he did not build or improve for purpose of U I i
sale.). QTY. PLUMBING PERMIT PEE
QTE
❑ I.as owarroflhe property,amexclusively contracting with licensed contractors to e FL�BQONE APN
onsu er the Ami(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE IA-rG 1
License l,ow dm nc)t opply t o an owner of progeny w ho builds or i m proves thereon,end
owcommucts forsuch pmjurs with accommelor(sUiunsedpursuanuo the CovtmceWa
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
zTTM5r
❑ I am exempt under See. ,B&P C for chis rcavon RACK FLOW PROTECT.DEVICE -S
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
$ ! WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I herebyleffirm that l have ecertificate ofcoment roself-imurt,oraadifocamo' FIXTURES PER TRAP RECEIPT#
Workeri Compensation insurance or a certified copy ehereof(Ses.3801 Lab C.)which PARK FEE Y N
save.all employee's under chis ps mrit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME
❑ Certified fa
copy is hereby waddled.
Codified copy is riled with the city inspection division. GREASETNDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(T his section need not becompleted ifthe Permit is for one hundred dollars($10) SEWER-SANITARY-STORM EA.2Di ENERGY FEE
or las.)
I cenifythut in the performance of the work for which this permit is aimed.I dust WATER HEATER W/VENT/ELECTR
not employ any Person in any manner so as to become subject to the Worker% PAID
Z
we
Compensation Lewsof Califomm. Date WATER SYSTEMTREATING Dom Receipt#
Applie
z 0 NOTICE TO APPLICANT:If,efer making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ FT. T
rLI) become subject to the Workers Conameaduon Provisions of the labor Code.you must
>
forthwith comply with such previsions or this pemdt shall be deemed revoked. BUILDING FEE
W (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction leading agency for the performance of TOTAL: ELECTRIC FEE
U O he work for which chis pemoie is issued(Sec.3097,Civ,CJ
Linder.Name PLUMBING PEE
V•' Lender's Address QTY. MECHANICAL PERMIT FEE
O U I certify that 1 have read this application and sum that the above inflammation is MECHANICAL FEE
ria 0. correct.l agree to comply with all city and county ordinances and state laws minting to PERMITISSUANCE
Uj bui lding construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U above-mcnrioned property for inspection purports. ALTERORADDTOMECIL
(We)ounce to arae,indemnify and keep harmless the City of Cupertino against
Ilubilities,judgmenes,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(1010,00 CFM)
in conuqueace of the granting of Nis permit.
AIR HANDLING UNIT(OVER IO,IXq CFM)
Signature of ApplicanVContmctor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,000 BTU) Data Receipt If
Will the applicant or future building occupant scare or handle hazmdour amomN HEATING UNIT(OVER 100,000 BTU) L
as defined by the Cupedino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 2 532p)? VENTILATION FAN(SINGLE RESID) �-
❑Ya ❑No
ISSUANCE RP•f,E
Willtheupplicamorfmart buildingoccupwtuuequipmemmdevica whichemir BOILER-COMP(3NP OR 10.1100 BTU) r GO Y
hazardous air contaminants ns dermed by the Bay Ara Air Quality Management BOILER-COMP(OVER 10,000 BTU)
DistriaT 13 Yes 9 U 1993
9Yec 13 No NEW RESIDENTIAL MGCH. 93 SQ.FT. 'y
1 have read the hazardous materials requircmems under Chapter 6.95 of the .f IIVu
California Health&Safety Cole,Sections 25505,25533 and 25534. 1 understand done CII Y ser iiiVAIr rr/f a l
if the huilAi lues node m e,e at it is my responsibility to notify the V -1#G�
oeenpan cmems ch .t onoe of a Certificate of
n�U
umM1 rc agcnr Dale TOTAL: ISSUED BY:
Ir OFFICE
alld/'e !/d CIS r , 10-f.0 At M��
X� s� f�a
� �� r
/ D64
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too
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LUWE D
NOV 3 0 1993
eLoa.Cin OE CUPEFMRQ L