25216 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOBI MUI ..BElycrRICAL PCRMITNO.
APPLICATION/PERMIT PLUMBING-MBCIIANICAL �Cn'I
BUILDINGDIVISION BUILDING PROJECT IDKN'I'I FICA'TION J G 1
BUILDING ADDRESS: }/. SANITARY NO, APPLICATION SUBMITTAL DATE
I 1 �6 1 Kase vna�rie f3i UNITN r LO p# f_ _�
OW SNA E: Pf10NE: CONTRACTOR'S NA LIC NO: (;i
ON O3 N/C CONTROL.'
RCIIII'I!Cf GIN iliR: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QT'Y. GLI>CTRIC PERMIT PEE BUILDING PEIiMI'I'INFO
IILDG ELI!CI' .MECH
El
PERMIT ISSUANCE —' �TTAy-,
LbMNSCDCONTRACTOR'SDT:CLAtATION APPLIANCES-RISIDEN]'IAL JOB DESCRIPTION
Zoiz Iherchy option that l am licensed anderprovisions of Chapter9(commencing with
LLI OO Section ad effect.
on3 of the Business and Professions Codd,and my license is in ppNRhS /N �
C full force and effect. ,F(J�
Fity License Class Licp IIP T0200AMPS
m Q y DaeContractor 201-BOB AMPS
Z8N7�. ARCIIITLCT'S DECLARATION OVER I000AMP5 SQ.FT.FLOOR AREA E/SQ.FT'.
OZ-0 I understand my plans shall be used as public records.
F y�J SIGNS ELECTRICAL
q��dd J Licensed Prnfcesional
Lys 6 that
I.-Bempt fr DECLARATION SPECIAL CIRCUIT'/MISE,
sea Oa V I hereby attire that 1 am exempt from the Cessions Co License Isw for the
u130.tFii Which
orquirdsape(Section]0365,Busher.improve,
diiali Cade:Any city mcou MP RO LE INST.
��; which rcyuiresu'ermine wuaammL slat.improve,Demolish,orrepairnduatertu
W2 politics its issuance,also noaims the applicant forsuch permit m Ele eeigned smmm r 1
�C G O that he is licensed pursuant to the provisions of the Contmcmrs License Law(Chap
dqe� 9(commencing with Section 7000)of Division 3.fthe Business and Professions Cn )MP11, EC RI VALUATH0Wpn
,Z
y , nrrhat he isexempt therefrom and the hmisfor the ullegedexemprion.Any violatinnu OUTUffS-SWI HES-FI
1-ZQ Sec(ion]OJLS by uny applicamfora perni(subjects the appliconnoocivil penehy of Ga .7 l/CJ
rd
re than five hundreddnitoe(E500). IIIre", elmire properlyormyemration, SQ'1' ' STORIES 'fYPfiCONSTRUCi'ION
Lo the work.ead rhe strumaeknot intended or offered forsnhe(Sec.7fH4,Business
ofessions CadeTheComnnorslicenseIsw doesnotapplyman ownerofywhobuilds of improvesthereon,and who date such worthimself.,thughployees,'nodded masuchim'rovemcntsare not areadedmoffcmJ for sale.B OCC.GROUP RIS.UNITS
however,the building orimprovement is sold w4bin one year.fer mplmion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as ownertdthc properly.umex<lusively mmrnding with licenud contracmrsm QTY. ;PLUMBING PERMIT -. FEE FLOOD ZONE APN
construe the Project(Sec.7014,Business and Pnfeaions creno Tat Convector's
License l.awdaes not applyto an ownerofpropeny who builds or improvevherean,and PERMIT ISSUANCE
who contracts for such projects with a ornamentals)licensed pursuumt to the Contmnor's ALTER-DRAIN&VENT'-WA'Tf!H(EA) TEF,SUMMNFEES
License Law.
❑ 1 am exempt under Sec. ,B&P C for this rcmon BACK FLOW PROTECT.DEVICE ' IDB �
SANITARY Y
i Owner —[)are— DRAINS-FLOOR,ROOF,AREA,GOND. RECEII
WORKMAN COMPENSATION DECLARATION SCBOOLTAX Y
❑ Ihemby affirm(halheve acmifinm of consent to selLinsure,orattnifi<am of FIXTURES-PER TRAP RECEI
Workera'Comp,mation Insurance or o certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y
covers all em to ce'a under this t. RECEII
p y Penni GASEA.SYSTEM-I INC.40UThETS
Policy p BUILDING DIVIS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished,
❑ Cenified copy is filed with the city inspection division, GREASBANDUSTRL WASTE TWERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSAFIONINSURANCE
(Tbissecrionncednor bec.mpletedifinepnmir isforonehundrW dollars(E100) SEWER-SANITARY-STORM E,.200FT. ENERGY FEE
others.)
I ceriify(hill in Om performance of tire work for which this permit is issued,I shall WAT17R HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof California. Data WATER SYSMMIRCATING pate Receipt#
O Z Applicant
Z C NOTICE10 APPLICAM':fl,utter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. 'TOTAL:
r ' hewn,subject m the Worker's Compensation provisions of the labor Code,you must
a7 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEC
W (� CONS]'RUCTION LENDING AGENCY SEISMIC FEL:
Uz Ihereby affirm that hem is a construction lending agency for rhe performance of
O rhe work far which this Penni(is issued(Sec.3097,Civ.C.) T AL: /a ELECTRIC FEE —�
Lender's Name
C) U Leader a Address QTY.'S MECHANICAL'PERMI7" P9P.' PLUMBING nae
1 certify that I have teal this application and sum that me above information is
correct. l agree to comply with all city and county ordinances and state laws redundant PERMIT ISSUANCE MECHANICAL FEE
,.0 huilding comannii.n,trd hefebyaummim repreacntmivesofthis city to enedii,onme CONSTRUCTION TAX
V z above-mentioned properly for maraschino Escarpments. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep hi mdesa me City of Cu no
liabilities,judgments,costs and expenses which may in any way inane it ins( i�yCs ANDLING UNIT(1010,000CFM)
in co scyuence egunring of pe ir. l(
AIR 11 BLIND UNIT(OVER 10,000 CFM)
S nuure ApplicaMCanvuctof Dam EXI IAUST HOLD(W/DUCII PAID
ITAZARDOUS MATERIALS DCLOSURE HEATING UNIT(TO 100.000 BTU) Dare Receipt Y
Will theupplicim a,future Boldin,ttom m drreor handle hom,d.us material HEAPING UNIT(OVER 100,000 BTU) T
as defined by rhe Cupertino Municipal Colic.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
12 Yea ❑No VENTILATION FAN(SINGLE RPSID)
Will me apphicamorfumm builiin encu ant use BOILER-COME 0HP OR 110,0011 BTU) ISSUANCE TE
g p equipmentQualit Management P A I D
hutant? no romxminorts as defined by me Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
O'svin]
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. JUN 18 1993
1 have mal the hazardous materials requirements under Chapter 6.95 of the
Culifomiu I lush@&Safety Cede,SIctinna 25505,25533 and 25534. 1 undersand that
if the building does not cumen0y have a tenon,that it is my responsibility to notify the V Vr Ii UF'tfiIIIV�
occupant of the ayuirements which must be at prior to issuance of a CeNficate of l
Occupancy.
Owner or numodud agent Date TOTAL: ISSUED BY:
OFFI �