25912 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB L - i,.1 TRICALPERMITNO.
o BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 25912
� vI n
BUILDING PROJEC'1'IDENTIFICATION G1L
BUILDING ADDDRMS: A SANITARYNO. APPLICATI/O'NSSUBMRTALDATE
UNIT# LOT# —( y
OW ERS NAME.: a PHONE: CONTRACTOR'S NAME: Cyd'
Oe1L �S'//1/�-U/ G ^4a 0-5 H�,G�Q , �K8�K6�f (,j�0 N)c cormeoL#
RCHITECTIENGINEER: LIC NO: ADDRESS: R]
CONTACT: PHONE: I�I
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELE PLUMB MECH
PERMIT ISSUANCE Qn, ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
®y;y Ihereby offimsthat l am licensed underprovisioncofChaper9(commencing with
FOO Section 7000)of Division 3.fthe Business and Professions Code,and my license is in PANELS
C full force and effect, m
Q uZZ UPT0200AMPSLicense Class Lic.# �
.e/- ��`�
H Q y Dute CoonOur 201.1000 AMPS V\\\ \\\
,ZEN` ARCHITECT'SDECLARATION OVER IOOpAMPS - SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I undersand my Alma shall he used ss public records, _
r ce� SIGNS ELECTRICAL
Q Licensed Professional
W OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
yX O a U 1 herebyaffirm Nat 1 em exempt from the Conaacmrs License Law for the �a
W 3 LL F- following reason.(Section 7031.5,Busntess and Professions Cade:Any city or county TEMP.METER OR POLE INSf. u V
yf3 which reyvires u Permit m construct,alref,improve,demolish,or repair my atmetuse _
�Ly i� pdoru ita issmncc,almrryuirn rhe applic�ntfmsuch permit tofileaaigrmW auummt POWER DEVICES
that he is Iiccnsedpuuuanno the provisions of the Contrecmra License Law(Chapter
9(commencing with Section 7000)of Division3of)he Business and Professions Code) SWIMMING POOL ELECTRIC VA UATION
(y_m or that he is exempt therefrom and the bssis for the alleged exemption.Any violationof OUTLETS-SWITCHES-FlXTURFS
-
aSectio 7031.5 by my applicant for a Permit subjects the applicant to a civil penalty of
n44
ot more than five hundred dogmas($500). NEW RESIDENTIAL ELECIR SQ.FT.
❑ Lusownerofthepropeny.ormyemPloYaswithwegeaeatheirmlecomperuation, STORI135 TYPE CONSTRUCTION
y will the the work,ond the structure isnot intended orofferedforsale(Sen.70,14,Business
and Professions Cade:The Contmeam s License Law does not apply tom owner of
propeny who builds or improves thereon,andwhodoessuch work himselfordamigh his - OCC.GROUP RES.UNITS
own employees,providedthat such improvementsem not intendedor offered for aale.If.
however,the building orimprovemem is sold within one yemofeumpletion,the owner- TOTAL: 3
builder will have the burden of proving that he did not build or improve far purpose of e
role.).
❑ I.mownerofthepropeny,unexclusivelycmn ingwimlicenu ono tomes QTY. PLUMEING PIJRMIT FEE PLOOD ZONE APN
construct the pmjeeI(Sec.7014,Business and Professiom Code:)The Contractors PERMIT ISSUANCE
License Low does not apply to an owner of property who builds or improves thereon,and
who commis(or each project with.conoactogs)licensed!pursumtmthe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. B&P C for thio reason BACK PLOW PROTECT,DEVICE O IDE FE
SANITARY Y_N
OwnerDate DRAINS-FLOORROOF, COND. RECEIPT
. , , , .
_WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I herehyaffnin that i have a certificate ofcoment toself-insure,or acertifrmeof FIXTURES-PER TRAP RECEIPT'#
Workers'Compensation Iniummenora ceni0ed copy thercof(Sec.3801 Lab C.)which PARK ME- Y N
coven ell employee's order Nis permit. GAS-FA.SYSTEM-1 INC.4 OUTLETSRECEIPT#
Policy p BUILDING DIVISION FEES
Company - - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished,
❑ Certified copy is filed with the city inspection division, GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA,20[t ENERGY FEE
mless.)
Ioinifythnthe performance ofthe work for which this Permit is iound,I sha11 WATER HEATER WJVENT/ELELTR
not emmanner m w u bj the Workers' PAID
O z Com n u ref Calif ie. D �'� � WATER SYSTEWILMTING Date Receipt#
Applicant
z NOTICE OA PLICANT:If.after making this CertiOcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
become subject to the Workers Compensation provisions of the Labor Code,you must
FFF"'rrr forthwith comply withsuch provisions ar this permit shall he deemed revoked. BUILDING FEE
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aflitr that them is a construction lending agency for the performance of
V O the work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE T
Lender's Name
O U Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and sure that the above information is
MECHANICAL FEE
cancer.I agree to o
comply with all city and county rdinmcces and state laws selaring to PERMIT ISSUANCE
burdingconrmumion,and hereby amhorizereprosenutivesofddsciry to enter upon the CONSTRUCTION TAX
V above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
fW0)agree .m =ass the City of Cupertino against
liabiliZ.,jud .cos ndex w chtanlonanywayaccmeagainHmid City AIR HANDLING UNIT(TO 10.000 CFM)
in con. e n in sppstmit. -
�f /„ 7 -���� p� AIR HANDLING UNIT(OVER IO,WOCFM)
Signature of ApplicantrCommetor -��j�J Dau EXHAUSTHOOD(W(DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Our. Receipt It
Will the applicant orfuture building Occupant amore or handle hamrdous material HEATING UNIT(OVER I00,010 BTU) - TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Section 255320o)7
❑Ya ❑No VENTILATION PAN(SINGLE RESID)
BOILER.COMP(3HP OR 1 W,000 BTU) ISSUANCE DATE
Will the epplicanmrfs res defined
by the Bay Arco Air Quality .nage ant p
hazardous our conumimnu as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,0110 BTU) Y1
DismcR
❑Vm ❑No NEW RESIDENTIAL.MECH. SQ.PI'. FEB 14 1994
1 have read the hemdous mattsials reyuirmrments er Chapter 6.95 of the I(-
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the CITY Vr ka UI`I;hJIIW)
occupant of the naf inamme which must be met prior to issuance of a Cenificed,of V
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED
OFFICE