25569 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •- -• - PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 5 6 9
BUILDING PRl1JECT IIIEN'TIFICA'fION
BUILDING ADDRESS: MOBS
SANITARY NO. /AAP'PLICAATTIO_NSUBBM/IITTTTALDAIE
O •V OBS �- UNIT# LOT# �F�Ll Y'G
OWNLI3SN E � /� O CO ONi LIC NO: 1
G (7� N C CONTROL Is
RCHITEC IENGIN:ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: ' " rBUILDING PERMIT INFO
QTY, a t FPI.ECT RIC PERMIT' FEE `
s, @LpG ELECT PLUMB MEC"
PERMITISSUANCE I�Jy ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
maz Ihereby affirm that l am licensed underprovisionsofaripta9(commencing with
Yid Section7g1 d eof fleDivisiont7 of the Business and Professions Code,and my license is in PANELS
F< full force end-flat.
Q License Cluss Lic.p UP To 200 AMPS
y y Date ConcomIN 201-low AMPS
z O,''i Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT:FLOOR AREA Y/SQ.FT.
O z—pp I understand my plans shall In,used in public recons.
s1 SIGNS ELECTRICAL
QY � Licensed Professional
6 OWNER-BUILDM DECLARATION SPECIAL CIRCUMAUSC.
xdxOyU I hereby affirm that 1 sum exempt from the Contractors License Lew for the
W 3 0.y
following..an.(Section 7031.1.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requites a permit to construct,eater,improve,demolish,in repair any someone
yah prior a.its issumrce,also requires Neapplicant forsuch permit to file.6,pediamement POWER DEVICES
that he is licensed promunt to the provisions of the Contractors License Law(Chapter
L a�' 9(commencing with Section 70g1)of pivisionJo(Ne Businessend Rofessiom Code) SWIMMING POOL ELECTRIC UA ON
,may arbor beta exempt therefrom and the basis for the alleged excmption.Any violation of OUTLETS-SWITCHPS-FIXTURES
Cz< Section 7031.5 by any applicant for a permit subjects the applicant maeivil Pmed"of
nit than five bund lerty,d it lars(5500). NEWRFSIDENTALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
� C owrac oat eproprny.ormyemployecswith wegaesthcirsolecompeneetion,
a. will othework,end the he Ccrc ictm intemdese af@redform applc.711.Bumorof
and fwh ora Code:The Conteeetors License law such
not apply 10 an owner is
poperywbobuildsmimprovesthemprovementsmrsourand essuch woh himselfurWside.Is OCC.GROUP RES.UNITS
conemployeeaping orimprsuch improvementsumnotimendedoraffern,the own r-
hnwevtt.the have
the b rimpm provinementg
i that he di in of build
fo,Neaweenf .TOTAL:
builder will have the burden of proving that he did not buil)m improve for purpose of
ale.).
❑ I,asrwnerrfthepropery,amexdusivelycontrazting with licensedconhecmrsm QTY. PLUMBING PERMIT FEE FLOODZONE pPN
ancon the project(Sec.7040.Business and Professions Code:)The Conracmr'e
License Lawdeasnm applyto anownerofpmparty whabuildrarimprovesthertan,and PERMIT ISSUANCE.
FEE SUMMARY
whocontrasforsuchpmjcetswithacomw tor(e)licensedpt, u.tto the Ca tiox,m's
License L (E
aw. ALTER-DRAIN&VENT-WATER A)
❑ I ern exempt under gee. ,B&P C far this rtason BACK FLOW PROTECT.DEVICE ID S
SANITARY Y N
Owner Duo RECEIPI'q
WORKMAN COMPENSATION ofem DE CLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOL TAX Y N
❑ theConforrnthat lhave
rrom orificateofconsemtmof(insure.o,Lm C.) hich FIXTURES.PER TRAP RECF.IPf#
Worker%Compensmion lnsunnro oracmifiedcopy thereof(Sec.3800,IabCJwhich PARK FFR YN
coven all em icuec's under this t. RECEIPTN
P Pe^nr GAS-EA.SYSTEM-I INC.40UTI.ETS
Policy q BUILDING DIVISION 1'PPC
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK F'EE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This serioe need not the completed ifthe pernit is far one bundoudollars($10(hSEWER-SANITARY-STORM EA.2(1 ENERGY FEE
orlesa.)
I certify that in the perfamumce of the work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ any prsoa in any marmcr so as to become subject to the Worker' PAID
Compasationlawsof Califomu. Dare WATER SYSTEM(TRE.ATING Date Receipt Is
O z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PI-MB. SQ.FT. TOTAL:
U) became subject to the Workers Compensation provisions of the Labor Code,you must 2
a5 find with comply with such provisions or this permit shall he deemed revoked. BUILDING HE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
�J- z I hereby affirm that them is a concoction lending agency for the performance of
U O the woh for which this permit is issued(Sec.30)7,Civ.C.) TOTAL: ELECTRIC FEE
lenders Name
Q U Lenders Address QTY,. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have it Nis application end wan that due above information is MECHANICAL FEE
7" 0. cored.l agree to comply with ell city and county entrances and state laws relating an PERMIT ISSUANCE
building construction,and hereby authorize representatives clods city in enmruponthe CONSTRUCTION TAX
L.) above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabillties,judgmems,toss and expenses which may in any way accmeagainstsaid City AIR HANDLING UNIT(TO Ig0011 CFM)
I.consust nee of the ting of Nis permit.
3 AIR HANDLING UNIT(OVER HL"CFM)
10— CW
rgna rt of AppliernmCmaractor Deb EXHAUST HOOD(W/DUC17
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IgI,IX10 BTU) Date Reccipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVFR 100,000 BTU) TOTAL:
a defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
01
❑Yes ❑No VENTILATION FAN(SINGLE RI'SID)
ISSUANCE DATE IL
Will theapplicanmrfutprcbuildingoccupantuxequiprnentordevicawhichemit BOILER-COMP(31IP OR IW,gp BTU)
anidous air contmninants ai defined by Ne Bey Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A D
imict7 /' 'i,a
❑Yes `13,N.
i, )
NEW RESIDENTIAL MECH. SQ.FT.
SEP 20 1993
I have rend the has materials requirements under Chapter 6.95 of the '
Caliremia Health&Safety CodeC.S¢tian 25505,25533 it 25534. I understood that
R ih building does not ct rattly have a tenant,that it is my responsibility to notify the
trepan of the requir mems which mus,h mer prim m issuance of a Certificate of CI I Y Ur 6ure� I I S
Occupancy. e
Owner or anthorized agem Dme TOTAL: ISSUED BY� v//✓• ■ 1
OFFICE