25254APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO I IIA) G -LL TRI AI,
APPLICATION/PERMIT PLUMBING-MECH^LAICAL
BUILDING DIVISION BUILDING PROJEtTIDERTIFICA11ON
PERMITNO.
25254_
BUILDING ADDRESS!
UNIT LOT#
/ l PZ -'11
SANITARY NO.
APIY/I ON SUBMITTAL DATE
NIiRSNAME : F::
r O
OXII A `G s—k
/ d
CONT OR' MIS: LIC NO:
N/C
C N'IROL#
ARCHI'YECT/ENGINEER: LIC NO:
ADDRESS —
CONTACT: PHONE:
Q1 Y. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB 'C
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 11 on l iocrosi undaprovlslonsor Chapter9(commeneingwilh
Fone000)of Uivisinn 3ol'the Business and ProksxionsCWe, and my license is in
APPLIANCES -RESIDENTIAL
PANELS
mal
JOB UBSCRII"�PIO�N�
fail
full tome and eft ^^
Lice C LIc is ' J
(1LJ'
UP TO 200 AMPS
p�1�/{r
I a k/a'�..`-(-`�/
Dam Comncmr
ARCIIITmium DECLARATION
SQ. FT. FLOOR AREA $/SQ. FT.
OVER 1000AMP5
OVER I000
I understand my plans shall be used as public recmds.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby n. Thal 1 um cxcusin from the Cessi n s Co License Law for the
follow ing hent , FF..hSection I to txav,I ss firm
Professions Code: Any cam Lawty foamy
_
TEMP. METER OR POLE INST. I
which requires a pannot to construct, alter, improve demolish, or repair any slrvcmm
prior in itsissuance. also requires the applicant fm such Permit to file a signed statement
POWER DEVICES
that he is licensed pursuant to the pmvisioru of the Contractors License Law (Clmpter
9( commencing with Section 70W)of Division 3 ofthe Business and Profession Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil patally or
.0 LION
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
DATE
nnunme than five hundred dollars($500).
[ILusowncrofthe property, ormyemployeeswith wages as lhcirsolecompcnsalion,
NEW RESIDENTIAL ELECTT.
STORIF,S -
YE CONSTRUCTION
Lndede 7044, Business
will do IM1ework, andthe The
no, u(Sec.
Comisnot's
Law does
and Professions Gde:'PM1e Cnntmemr's License Law does oat apply ro an ownu of
property who builds nr improves therton, end who dues such work himulf or through his
own employees. provided that such improvements am notinmaded oroffered forsale. If.
OCC GROUP
RES. UNITS
TOTAL:
however, the buildingor improvement is sold withinane yearofcomplaion.the owner.
builder rill have the burden of proving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
FLOOD ZONE.
APN
sax.).
❑ I, as ownerofthe pmpeny. ton exclusivelycontrazting wird licensed contmnors to
Import IM1e project (Sec. Ilk, Business and Professions Code) The Contractor's
License Low does not apply loanownerofpropeny who builds or improvesthcn:ori. and
PERMIT ISSUANCE
who contracts for such projects with a contmerons) licensed pur-mum to the Contractor's
License Law.
ALTER -DRAIN hVET(IS) N- WATER )
PEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
❑ 1 on exempt under Sec. , B & P C for this reason
SANITARY Y N
RECEIPTa
Owner Data
DRAINS- FLOOR. ROOF. AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Ihereby affirm Nm l have a ceriGcale otconsent to self-insum, or a certificam of
Workeri Compensation Innovative or a certified copy thereof (Sir. 3800. Lab C.) which
yap y�J-8 dryp�' ,�s`
Policy p 1 1. C7-1 w-^x.oL
SCHOOLTAX Y N
RECEIPT
FIXTURES - PER TRAP
PARK FEE Y N
RECHIPF#
GAS - EA. SYSTEM -1 INC.4 O(PLETS
BUILDING DIVISION FEES
.1.
Cninpan, n-1 C
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Cenired copy is hereby famished.
X'Cenified copy is fled with the city inspection divi.aion
GREASEANDUST RL WASTE INTERCEPTOR
GRADING ItiE
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOLI S FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need nut be camplaved ifthe permit is harvest hundred dollars($ 100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become stmart m the Workers
Compensation Lawsof Culifomia. Dale
WATER HEATER W/VENT/ELECTR
PAID
WATER SYSTEMO`RIiATING
Date Resciplk
Appliea.I
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. 19'.
TOTAL:
hecome subject to the Workers Compensation Provisions of the Labor Code, you must
forthwith comply with such provisions in this permit shell be dcemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency fm the performance of
the work for which this permit is issued (Sec. 3197. Civ. C.)
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Name
Lender. Address
1 certify that I have read Oi, application and qam that ILe above information is
cored. l agree to comply with all city and county ordinances andmave lawsrelating mPERMIT
ISSUANCE 5,
7
MECHANICAL, FEE
ALTER OR ADD TO MECH.
CONS'1'RUCI'IONTAX
building construction, and hereby aulhorim oprcse oilives of Nis city to enter uponthe
above mentioned proven for inspwion purposes.
AIR HANDLING UNIT (TO I y" CFM)
(We) agree m save, indemnify and me, to naleaa the City of Cupertino ageimt
liabilities,judgments. suets and expanses which may in any way accme against said City
AIR HANDLING UNIT (OVER 10.00(1 CFM)
in c ce of the granting f this coni!.
EXHAUST HOOD(W/DUCT)
PAID
Ig a re n[Applicant/Comnmlor Dee
HEATING UNIT(q'O 11(),0!10 BTU)
IS
IIAZARDOUSMATERIALS CLOSURE
Date Recciptp
HEATING ON] F(OVER 100.IXIO BTU)
TOTAL:
Will lhcapplic—I nr fumrebuildingoccupamamremhwdlehazardous movenal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
VENTILATION FAN (SINGLE RESID)
,
Cate Section 25532(x)?
❑ Yes ❑ No
Will lheapplicanmrl'mare BuilJingmcupam use equipmemordeviceswhichemit
BOILER - COME (311P OR IW.IKIO BTU)
Pf p' I;wIJsUANCE DATE
T M
hamrdous air contaminants it, defined by the Bay Amu Air Quality Managstmem
BOILER- COMP (OVER Ilk," BTU)
DislricR
11 ye, El No
AUG 51993
'IA
NEW RF,SIDFN'1I. II. IT.
SU MEC
1 have read IM1e barardous mmenals requirements under Chapter 6.95 of the
ia Health J, Safety Code. Sections 25505.25533 and 25534. 1 understand that
California
_
I iY OF CUPEH 1 IdU
if the building does not currently have a trnant, thin it is my responsibility to notify the
meapant of the requimme s, which must be met prim to issuance of a Certificate of
Occupancy.
ISSUED BY:
(loner nr ambovcd agem Dam
TOTAL:
vrrlct U