25915APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO .mNG-ELEOTRTCA -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAI.
BUILDING PROJECT IDENUN'ICA'TI(IN
PERMIT NO.
]5 5
L J J
25915
BUILDING ADDRESS:_
SANITARY NO.
APPLICATION SUBMITTAL DATE
6f f1CF7��A 1-2441 Ac
744 ' UNIT# 1,0'fp
OW h N B: PHONE:
CONT CTOR'S NA li: LIC NO:
,�a.
C9°�
N/C
❑
CONTROI, p
A CI1OECT iN I iER: LICNO: -
ADD? SS:
CONT'ACf: PHONE:
4
z $ o -R$ t i { . ,�G.'>.
QTY t?F' @ ELECTRIC PERMIT -
BUILDING PERMIT INFO -
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
a
IC7I D El
Lam.
LICCNSED CONTRACTOR'S DECLARATION
Iberebyaffirmlhm l aralicensed tinderpmvisionsefC'bapter9c(annumaing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Seelion 7011d)al Division 3 of the Business and Profewicns Cale, and my license is in
afel
License Class
PANES
Ck` `�[
Duall¢
Convector AS%
201 -1000 AMPS
U tl
ARCHITECT -S DECLARA ION
1 mcbmaind my plans shell focusedm public records.
OVER IWOAM
A
y
SQ. PT. FLOOR ARRA(
$/SQ. Pf.
SIGNS ELECT?
Licensed Profnuionsl
OWNER-Bempt
DEhe
SPECIAL CI 1 t
i
I hereby fr CommION
License Lew for the
Thal I um exempt from the Camaro
TEMP. METER OR POLE INET.
maestro
following mama. ((Se
(Section 703L5. Bariness and oli Code: Any tiny or county
Co
e
which requires a#,mit toconstruct, alter improve,deernsha or firepairanys,mcmm
improve, de
prior es its issuance. also requires the such #nmol mLic a signed statement
POWER DCVICHS DATE
afar
provisions
That u islicensed p Section
the provisionsof the the Buss Business ad Pre Use (Chapter
9(cnmmencing with Seelion 7") of Division3afthe Business end Pmfeasiom Cade)
SWIMMING POOL ELECTRIC
VALUATI
or than he is exempt merchant and the basis for the silage) exemption. Any violaonn of
Seelion9031.5 by any applicant for ape.it subjects the applicant toe civil penthyaf
! �DO d
/
OUTLETS-SWITCHES-PIXTGRNS
not more than five hundred dollars ($500),
❑ 1,asownerofmhepmparty,ormyemploymswithwagesastheirselecompensation,
NEW RESIDENTIAL ELECfR _SQ. Fr.
STORIES
'TYPE CONSTRUCTION
will do The work.snd the suucmm isnot intended oroffered forcale(See. 7044, Business
and Pmfnnions Cale: The Contractor's License Law does not apply to an owner of
pmpanywhohuildsorimproves ihemon, Cod whadoes such work himselfarthmough his
employees, Prov ideJ kam such impmv<men ta ve nm imrnded or offered for sale. I f,
OCC. GROUP
RCS. UNITS
TOTAL:
however, the building orimprovement is sold within one yearofcompletion, the owner-
builder will have the burden of proving that he did not build or improve 1'or purpose of
QT'Y•! -PLUMBING PERMIT FEE
�.3 a' -
sale.Is
property. containing Cook licensed wntmctarsm
❑) 1, as owner of the n y g
FLOODZONE
APN
Business
Business Ipe Professions Crimp ova thereon, and
Licatmct IIIc project (Sec. to an
LittnscfawdoesnotapplyumnowacommepenywhnsedpumimpmveeNemon,and
PERMIT ISSUANCE
wet,mm rade for such projects wiNacommmor(s)licensed pursuant to the Contractor
License Lew.
ALMS (EA)
PGE SUMMARY
❑ 1 ren exempt reader Sec. , B & P C far this mason
BACK FLOW PROTECT. DEVICE.
D
OUTSIDE
SANITARY N
RECEIVE'#
Owner -Did-DRAINS
- FLOORROOF, ARU,COND.
,
WORKMAN COMPENSATION DECLARATION
SCl/OOLTAX YN
❑ Thereby xffirm lhellhvvevicenilicam of amsem mself-ireurt, orncerti0cum of
Workcrosi Compensetinnlnsur�nce orac<nifiedc�py therw c.380lLLab C.)whtch
FIXTURES-PER'fRAP
RECEIVP#
PARK FEE. Y N
covers all <mploj'ce's unyder t 1q�n�Is
PolicyN / � Z 4 a y _
GAS - EA. SYSIF.M-1 INC. 4OUT 'LLTS
RECEIPT p
BUILDING DIVISION FEES
JJ
Company �i /} �ilL
GAS - HA. SYSTEM -OVER 4IEA)
PLANCHECK FEE
❑ Certified copy Is hereby (ueished.
Certified copy is filed with the city inspection division.
ORI?ASFJINDUSTRLWASTEINTERCF.FfOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
OREASETRAP
SOILS FEF.
SEWER -SANITARY -STORM P -A. 20OFT
ENERGY ITHI
(This section neednot be Completed ifthe permit is far one hundred dollars(SIM)
or less.)
WATER I[EATER W/VENT/ELECTR
I certify that in the Performance of the work for which this permit is issued, Ishall
not employ any person in say manna are as to become suhjm to the Workers'
PAID
Campensmion Lawsof Califomie. Dore
WATER SYSTEM11REATING
Dae Receipt#
Applicant
NOTICE TO APPLICANT. If. after making this Ccroficam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subjectto Ne Worker's Compensation provisions of the Labor Cale, you must
forthwith comply wilt such provisions or this permit shall be deemed mimed.
BUILDING IIEE
SEISMIC FEF.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a construction lending agency for the Performance of
the work fm which this permit is issued(See 3097, Civ. CJ
lenders Name
TOTAL:
ELECTRIC PI?C
Lerldars Address
1 certify that 1 have read this application and state that the above Information is
,moron. lagrte to wmplY with ell city end County ordinances and stale laws rotating to
-
Qp �;' y` . MGCIIANICAL'PERMIt FGP:<
1 i I
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FGF.
building contraction, and hereby aathnriae represtafthres ofthis city to enterupon the
above-mentioned Property for inspection purposes.
ALTER OR ADD TO MECiL
CONSTRUCTION TAX
(We) agree to save, indemnify and keep homeless the City of CLpenino against
Iiabilides,judgmcros, coslsand expenses which may in any way accrue against said City
AIR HANDLING UNIT (T'010,000 CFM)
'nCo encam
pfthe gling Nispeelil.
/I/_9�
AIR HANDLING UNIT (OVER 10.000 CFM)
SignatVilifAlptilicarViConerecter Date
EXHAUSTHOOD(W/DUCT)
PAID
HEATING UNIT(TO 100,000 BTU)
Date Receipt p
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building retraining smrc or handle harnrdous material
as defined by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
IIP.ATING UNIT (OVER 1 W,WO BTU)
TOTAL:
VENTILATION PAN(SINGLE RESID)
F C
7�n0
Cala, Section 25532(e)'l
0 yes AN.
Will the applicant or future building excupnm use equipment or devices which emit
hams ous air eamarainsnls as defined by the Bay Arta Air Quality Management
District?
11 yes INN.
I have read 'be hazardous amends requirements under Chapter 6.95 of the
BOILER- COME (311P OR 100.000 BTU)
ISSUANCE DATE hh
- / V '
P A 1 D
FEB 14 1994
BOILER - COME(OVER IW,000BITJ)
NEW RESIDENT' IAL MECH. SQ. ET.
Califs ram Health & Safely Cade, Sections 25505, 25533 and 25534. 1 understand Nal
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant o rcyuimmems w " h mus, be met prior m Issuance of a Certificate of
/s
CO Ur k Urrri I IIrU
Occupan . a - /-Y _
. -
ISSUED BY: 41AW=J V\ VC
Owner or aeorixed agent I
TOTAL:
OFFICE