25507 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO rtEMBING-MECHANICAL PERM"'"°' ^��0 7
APPLICATION/PERMIT PING PROJECTIFIC
BUILDING DIVISION BUILDING 1'HOdF:CT IUENTIFICA'1'ION
BUILDING ADDRESS: r 40C
)(^(�9 SANITARY NO. APN.ICATIONSUBMHTALDATE
x /J
/I C/t UNIT. �`OTa T/
OW SNAME PH C '1'OR:S A E: LI O:
/l Ig /L2�T NIc co r col,a
'CHITIiCI'Ai`IGINEHR: LIC NO: ADDRESS, ❑
n
CO PHONE:
V 1,6 s x _F<f QTY. _'ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E PLUMB MliCll
PERMIT IS ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
G0LD Ihereby a7") rhrmthml 3 ofthasedunss provisions g sk, (commencing with TOB DESCRIPTION
1+100 Sall face andof Division3af nM1e Business and Prof ssions eBd linens rim pANFELS a'a�
CUF f.i.m face and ellen (e/f
LicenxcC L;c.p UPT0200AMPS
y 6 d Dale Conw<no 201-1000 AMPS
Fy ARCHITF. IT DECL N SQ,IT.FLOOR AREA g/SQ.Ff.
t'0y I understand my plans shall be used as public mcaNs. OVER 1000 AMPS
OZ—❑
N
W SIGNS ELECTRICAL
Q_ j Licensed Profdssinnei
W�y W 6 hotI.OWNER-BUILDERtempt fr.the CoATION SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt from the Gonion Co License ittw bodies
m'3ah whichingmasoaermit toconstrut,altessandove,de Professions Code:Any city structure TEMP.METER OR POLE INST.
1_1_'06
which requires a p•.rtn;t m construct,alter,improve,demolish,or repair any swcwrc
5-w}� poor It,its ismarea.Ms.requires the applicant for such pemaU.file.signed statement POWER DEVICES
pew>.;F
tha he is licensed pursuam to poscNions r,ha Contractors License Law(Chapter SWIMMING POOL ELEC RIC
n Kota 9(cam he is exempt
emSections and
Division Sof the Business end Profession Cad e) Up'uON
m_y Snhmhe31.5barry a6romand the Permit sujeasegdeumant to Anyviolationpsernity of OUTLETS-SWITCHES-FIXTURES rK
F'ZQ hatmaratho S v anydreddollforapermir subjects the applicant to ecivil penehy of
K�onot marathon yempl NEWRESIDENTIALELECTR _SQ.FT.
❑ Lthe wrk,a thepstructre isammployed orofwagoasack,(sale compensation, R TYPEI CONSTRUCTION
a3= will dotheandtheThe mrcisnmin¢nense Law dfs notapplyttr14.Bnir ss
of DAT
and Professions Gdc The Convucmr's License Lew docs not apply m an owner of
pmpenywhobu Lilsorimproveathermn,andwhodoessuch work hiossclfor Juough his -
own employees.provided that such improvermn¢arc not imcnddor offered Initiate.If, OCC.GROUP R13.UNITS
however.the buildingor improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
ia1u)' QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
❑ Lv he ejfthe Sen.70,am u,in sivdnconvac ime,Code)
The Cish norsm
cpcansic ad owtail(Sec."Iraq,Business and PrOfic.ywhobions Code:)The Contractor's
whocol,zwdoes such
pplyeawithacafproperry whosed pursuant
tothe hcrmaand PERMIT ISSUANCE'
who.Law.for such pmjwls with enrrntmemr(s)licensed pursuant mnhe Connracroia
liarac Law, ALTER-DRAIN&VPNT-WATER(P✓1) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for ths mason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE Y N
Owntt Data DRAINS-FLOOR,ROOF'.AREA,COND. RECEIPT It
WORKMAN COMPPNSA'I'JON DECLARATION SCHOOLTAX Y N
,❑ Thereby affirm nM1n lharcecenificae of conunuo xlf-insurt.on urdf am°f FIXTURES-PERTRAP RECHIPrp
Wmrkeri Compemntion Insurance or a cmified copy thercof(Sec.3800,Lab C.)which PARK FEE Y N
crsdl employce s under this famorb. GAS-EA.SYSTEM.I INCA OUTLETS RECEIPT a
Policy# BUILDING DIVISION FEES
Compary
❑ Cenifid copy is hereby famished. GAS-HA.SYSTEM-OVER 4(EA) PLANCHICK FEE
❑ Cenitied copy is filed with the city inspection division. GREASEINDUSTRI,WAS TE INTERCEPTOR GRADING FEE
C13RTIFICATE OFEXEMPION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tussection need not he completed ifthe permit is for one hued(ddollars($IN) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
orless.)
I nearly that in the perf.maturica.fichic work for which this Permit is issued.I shall WATER HEATER WNENTIELECTR
or employ troy person in any manner so as to he`trLne Subj*19YINe Worker' PAID
Compensation la ami ate a-i f/ WATERSYSTEMfIREATING Date Receipts
Zz Apli nam
O NOTICETOAP LICA ter making this C<nifi<ale of Excmpni......should NEW RESIDENT IAL PLMB. SQ.FT. TOTAL:
y become subject o the Worker's Compensation pmvisinns of the labor Code....must
� > forthwith comply with such provisions or this permit shall be decmd rcvokd. BUILDING ME
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a cansavation Fending agency position perf.ce of
U O TOTAL: ELECTRIC FEE
the work for which This pertnit is issued(Sec.309],Civ.C.)
Lender's Name
0 U t.dndIcAddress QTY. MECHANICAL PERMIT FEE PLUMBING ME
U 1 cavity that Chane rend this city
and cou ane sate that the above information rmnion Fs
cording eommmcomply herhall yatiryand countyconductressesmdciain cater upon the PERMIT ISSUANCE MECHANICAL FEE
buildi(~ Z abime.gcomm�ed o pert hr,insputhoriumpresenmlives of Nie city memm upon the
U z CONSTRUCTION TAX
abo (We)pe a pmpeeyfor Inspersion ka,hu s. ALTER OR ADD TO MF.CH.
J (We)agree nt save,indemnity and keep k rmlc s Bin City cr u
Cpertino against
liabililiea.judgmems,cosrs and expenses whic yin any way acerueagalnt said City AIR HANDLING UNIT IT I0.000 CIM)
in conuyumcc ort this pc
L AIR HANDLING UNIT(OVER 10,000CRO)
Signwrc nw Dam CXHAUSTHOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE IIEATING UNIT('10100,000 BTU) Dam RecNpt It
Will the applicant or future building occupant store Or handle haasMous materiel
n defined by the C.Iwnino Municipal Coca,Chapter 9.Tl.and roc l leabh and S.my HEATING UNIT
(OVER IOO,IXIO BTU) TAL:
Cede.Section 25532(.)? / VENTILATION FAN(SINGLE RESID)
❑Yds L�No
BOILER-COMP(3(314P OR 100,000 BTU) ISSUANCE DATE
Will theapplicem or ruwmbuildingcecupam usecyuipment ordevices whichemir
haacadous air comunce t fined by he Bay Are.Air Quality Management BOILER-COMP(OVER 100.000 BTU) B ® ..
District?
❑Yes Nn NEW RESIDENTIAL MCCII. SQ.Fr.
1 have read the harallous materials requirements under Chapter 6.95 of the AUG 3 0 1993
California Health&Safety Coda,Sections 25505,25533 and 25534.1 undersand that
ifrhebuildingdoNomOlmsml harcarcnant,that it is my resrymaibiliny to notify rhe
napantanne mya; .�yldnmostta is�a:mne nracmirnam mr �illY Ur GUrertlllvU
Oce
upancy. /f/
Owner •da Data TOTAL: ISSUEDBY: