25623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIL"ING-ELEc1'aTGa• PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT.
PLUMBING CT ID
3ANIFIC 25623
NUILUING FRO1F.(.T IIIBNT'IFICATIQN
BUILDING ADDRESS: �'s^ SANITARY NO. APPLICATION SUBMITTAL DATE
.x4 - UNIT# LO'I`a lV-4�
O ERSNAM?: PHONE: CONFER ORS AMI?: LIC NO: NIC CONTROL#
resoL� o &M6�
ARCHITECl/ENGINELR: LIC NO: ADDRESS r ❑
CONTACT: PHONE: }aA4 : BUILDING PERMIT INFO
Qk"Y`� ey¢7R1$IPER§I T,n $a* FEC
BLDG ELECT PLUMB MLCH
PERMIT ISSUANCE El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC!Ulpi'ION
Qd`z Horebyafftm that lam licensed underprovisioes of Chapter9(commencing with
P02 Section]8001 of Division 3 of the Businea end Pro6ssiov Code,end my liana ism ppNEI3
CU fullforce andeffect. UPTO 200 AMPS LJ`J\(�� Ilr•�
N,^C, License Class Lic.p
Qoo Dam Contractor NM 201-IBM AMPS
z0_yd A CI III ECI"S DE LARATION OVER 1000 AMPS SQ.PI'.FLOOR AREA $/SQ.Pr.
C a r,tend yylans 1 Jas Publicovmd.
�vrtu1 / �i�iJ/JJ%/�� SIGNS ELECTRICAL
QYf,j Lice dRo essionul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
px,OaU 1 hereby affirm that 1 am exempt from the Coners ares License Lew for the
an following reason.(Section 7031.5,Business and professions Code:Any city memory TEMP.METER OR POLE INST.
Oy which requires u permit to concoct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed surmmem POWER DEVICES
WG Om that he is licensed Pucwact tp But,provisions of the Cmmonsors License Lew(Chapter
p-k�LL 9(cummencing with Section 7003)of Division 3 ofthe Business and Professimrs Code) SWIMMING POOL ELECTRIC VALUATION
W_H onhat he is exempt therefrom and the basis for the alleged exemption.My violation of OUTLETS Senior J031.5 by any applicant for a permit subjects the applicant on civil penaity of O
not...,ban rive hundred dollars($500). NEW RESIDENTIAL ELECfR
ElI.mownerofthepropeny,ormyemployeeswithwagesmtheirsolecompensatian,S -SQ.PT. "TORIES 'ITPE CONSTRUCTION
p, will dothe work,and the structure isnot intended proffered forsole(Sec]014,Business
and Prpfosslonx Cale:The Contractor's License Law does not apply to an owner of IC/
pmpertywhohuildsnrimpmves Nereon,and whodoessuch work himselfordroughhis OCC. RES.UNITS
wnemployees,provided that such impcoementsm,not intended orolfercd fmwle.If.
however,the building orimpmvemem is sold within one yearnfcomplefion,Neowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
b...
❑ hasownerufthe property,am exclusivelytmmrs
contraeting with coneto QTYil `%.i�i 'PLUMDINC PERMIT FF:E, FLOOD ZONE APN
onstruct the project(Sec.7044,Business rad Professions Cale)The Convacmr's
License Lawdoes not apply m an ownemf property who builds or improves thereon.and PERMIT ISSUANCE
whocontracis for such projects with a comramor(s)licensed pursuant to the Contractor's ALTER (EA)
License Law. FEE SUMMARY
❑ 1 am exempt undtt Se<. B&P C for this reawn BACK FLOW PROTECT,DEVICE UT ID- d
SANITARY Y N
Owner Date RECEIPT#
GRAINS-FLOOR,BOOK AREA,GOND.
WORKMAN COMP ENSATIONDECLARATION SCHOOLTAX Y N
❑ ers'Co perovarffiran hatlhave rance orta certanf coreennosf(Sesure,or Lab C.)c te atwhich
RECEIPfp
FIXTURES-PER TRAP
Workers Grployeeionlerthisermit. fled copy Ncreof(Sec.3tlW,Leb CJwhich PARK I'GE Y_N
covers all employce'.v under this permit. RDIVIIPI'p
Policy# � GAS-EA.SYS'1'IiM-I INC.40UTLI3T5 BUILDING DIVISION Fl?F.S
CompanyGAS-EA.SYSTEM-OVER4 EDO PLANCHECK FEL
❑ Cenifiedeopyisherebyfrdla ed.
❑ Cenificd ropy is filed wiN beciry inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE:
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS HE
COMPENSATION INSURANCE
('T his section need not be completed ifthe Permit is forom hundred dollars EURd SEWER-SANITARY-STORM EA.200ET. ENERGY FEE
or less.)
I cenifythat in performance of Ne work for which this permit is issued,l shall WATER IIIiATIiR WryENT/ELECTR
not employ anyperson in any manner so as to become subject to the Workers' PAID
Compensationlywsof Califamie. Date ATER SY EM/rRFATING ,� Dole ReceiptM
Q z Applicant
7 0 NOTICE TO APPLICANT:If,offer making this Cenificale of Exemption,you should RESIDENTIAL PLMB. SQ.FT. TOTAL:
F r7 became subject to the Worker's Compensation provisions ofthe labor Code,you must
forthwith comply with such Provisions or his permit shall be deemed revoked BUILDING THE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby am ton ffirthem is a emeaddeficot lending agency far Ne perfomunce of ELECTRIC ITE
O the work for which this permit is issued(Sm 3099,Civ.C)
it. Lenders Nome l
0 F Lenders Address QTY. " MLCIIANICAL PERMIT' -FEE PLUMPING FEEL) I certify bar 1 have reed this application and state Nbo
at the above rm
e mfoation n ` s t ° 4
amec,.Iagree us<Amply with all city and county oNinences and nme laws relatingm PERMIT ISSUANCE
MECHANICAL FEE
F-' building construction,and hereby authorizereprcsenta0ves ofthis city to enter upon the
U above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUC'T'ION TAX
(We)agree m save,imlemnify and keep factors,the City of Cupertino against
1 bilities,judgmrnts,testa andexpensea which may in any way same against said City AIR HANDLING UNIT(T010.000 CIT)
quer of the ri
AIR HANDLING UNIT(OVER IQfNq CIM)
,n tore of Mplinmt/Contmpmr Dote EXHAUST HOOD(W/DUCT} PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO IW,000BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous mamrod
av defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Heath and Safely HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25532(a)]
El Yes 1:1 No VENTILATION FAN(SINGLE RISID)
Will the apPlinmt orfuwre M1uildingoccupanmse Wuipmem ordeviceswhichemir
BOILER-COMP LBIP OR 100,000RTU) IS DATE
hnzeNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) OCT 111993
-Jistrictl
11 Yes El No NEW RESIDENTIAL MECH.-SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the e CM Ur UUrth I IIVU
if the uil Health s Safety Code,Seniums 25505,25533 and responsibility
I understand that
ifthebuilding finesnot
ments yhave atenant,e,itis myyssuanceiofa emmlfy of
occupant of the requirements which must be mar prior m Isemnw of u Cmifipme of
occupancy.
Owner or authorized agent Data TOTAL: ISSUED RP
OFFICE—