25402APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING - .LI. , AI,
CITY OF CUPEAPPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION
N LI . , BUILDING PROJECT-IDF.NDF'IC.A
BUIhI)INGADDRE'S: %� /��'J �/ /pys�/�
L 05�� SUN/z/SE _PR �IT C �/ ° LOT is
2540
41TWE-i�7
OWNERS NAME: T�/ V/ yPJIO E:
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CONTRACTORS NAME: LIC NO: ('-�,a l' �J'
We r (� / d_J (�, G/U/ fC
ADORES :90 n �.'f J\ ❑
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ARCII`'1'I_CI'/IiNGINEL�7•�K U LIC IV
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Q7'Y, ,ECTRIC PERMIT PIiE
HUILDING PERMIT INFO
LDG L1EC'I' PhpMll MECH
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PERMIT ISSUANCE O
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P400
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LICENSED CONTRACTOR'S DECIARATION
lherebyuffirm thaU am licensed underpmvisinnsofCTapar9 (commencing with
Seen, n]0(Ilpnf Drvr4 3afthe Fastness and Professions Cade. and my�slicense is in
full force end effect. C '1 /
Licenx Class Lic.M_�rl_ _GG -J
Date Contracmr
APPLIANCES-RISEDENfIAL
PANELS
UP TO 200 AMPS
]OH DESCRIPTION
/� �/r�
��1-�l� g
�_ 1YFLOOR
201-1000AMP5
A II'I'IiC-S DIiCL li 1
I understand my a ell Ire usod ar p rewNs.�
OVER 1000 AMPS
SQ. R. FLOOR AREA
E/S(]-FT.
SIGNS ELECTRICAL
J
yoe<
Oe.
a¢v[¢-irallmwing
rJ` O J
ml n O R-BUILDP,R DECLARATION
I hereby affirm that I am exempt from the Contrcmes License law for the
reason. (Section]031.5, Business and Pnrfcssiona Code: Any citymomma,
which .,at., a permit ser construct, aper, improve, demolish, or rcpuir any structure
SPL'CIAI. CIRCUIT/MISC.
TEMP. METER OR POLE INST.
i�Y�m
e5<0
•4�F,4
its issuance, also the applicant forsuch wino file a signed statement
prior yuims PP pe e
that he is liermcd Emsaam m the provisions if Conovarss License Law (Chapter
9 hommencing with Section 700D) of Division 3.f he Business and Professions Code)
POWER DEVICES '
SWIMM ING POOL BLEM R IC
VALUATION
al Mso
nation he is exempt herefrom and the basis for the alleged exemption. Anyviolutianof
Section 7031.1 by any applicant for apennit subjects the applicant to acivil penohyof.
1
ETS-SWITCHES-PIXTLRE$
:10 IRK
gOUTL4
<n
sat4 .
yy_
not more than Ove hundred dollars($500).
❑ hmownemfB¢prnpenY.nrmyemPloYres withwegesostheirsolecompensation.
will do the work, and the structure is not intendedaroffered for sale (Sec.]044, Business
'NEW RIiS1DEN'1'IAL ELECTR _SQ. Pf.
STORIES
TYPE CONSTRUCTION
and Professions Code: The Commodes License Low does not apply to an owner of
.
propenywhobuildommunproves Remained whodoes,med wnrkhimxlfmthmughhis
own employees, providN thatsuch improvements am mainter ted reoffered for sale. If,
GCC.GROUP
RES. UNITS
'TOTAL: r
however, the building or improvement is sold within one yearofcomple0on, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sole.).
❑ ],as ownernfthe property, ten exclusively contracting with licensed contractors to
MOOD ZONE
AI'N
construct the premier (Sec. 7044, Business said Professions Code:) The Conrmeor's
License Lanedmas not apply no onmenernfpropertywhobulldsor, improves thereon,and
PERMIT ISSUANCE -
who contracts for such project w41hnwnnuemr(s) licensed pureuam to rho Conoamods
License law.
ALTER- WATER (PA)
DRAIN & VENT -
a c
I'LL SUMMARY
❑ 1 nm exempt undo Sec. , B & P C for this reason
-
BACK FLOW PROTECT. DEVICE
SID ES
SANITARY Y N
Game, Date
DRAINS- FLOOR, ROOF, AREA, GOND.
RUCHE ME, #
WORKMAN COMPENSATION DECLARATION
$CIIOOLTAX Y
I hereby ad rm that 1 have a certificate of consent to self -insure, m n certificate of
rkers'Campansmionlruumnce oraanificdcopy Neeof(See.Jg00. Lnb CJ which
FIXTURES-PF.R TRAP "10
RECIBP-b
PARK PI3E YN
GAS - PA. SYSD!M-I INC.4 OUTLETS
rs all employee'a under this permit.
Palsy g
RECIiIPI' M
BUILDING DIVISION FEES
Company
GAS - EA. SVSTEM-OV-:R4(P.A)
PLANCItECK IIiE' '
El Certified copy is bercby famished.
GRFASPJINDUSTRI. WASTE INTERCEPTOR
GRADING HE ✓
Certified copy is filed with the city, inspection division.
/1
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASH*LRAP -
SOILSFEE t O
COMPENSATION INSURANCE.
NEWER -SANITARY-S"T ORM HA. 200111.
ENERGY FEB
('Ihissea(ianneednar be completedllThe permit is far one hundred dollars($100)
or less.)
WATER 11 EATER WNF.NI'/ELECTR
I ccnify that in the performance ofthe work for which this permit is issued, l shall
not employ, any person in any nunner so as to become, subject m the Workers'
PAI
z
s
�>
Compensation Lawsof Califamia. Data
Applicum
WATER SYS f 1' t Gly dDue
Receiptk
NOTICETO APPLICANT: If, after making this Ccrnificmeof Exemption, you should_NEW
become subjeunothe Worker's Compensation provisimemdr. Labor Colli mustp
forthwith comply with such provisions or this perrnit shall be deemed revoked.
RESIDE PIAL PLMB.i- S .P.
dV�
•lppAl.:'
BUI DING ME
DATE
(�
O
F
WI
6.
�
Z
CONSTRUCTION LENDING AGENCY
1 hereby affirmsthat there is o construction lending agency for the Performance of
the wad; lin which this permh Is Issued (Sec. J09], Civ. C.)
Lender's Nano -
- TOTAL: S:Ab —
ICFFF
a
QTY. MECIIANICAI. PERMIT FEE,Q
PLUMBING FEE
I<ndcra Address
certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinenece and state laws relating to
building construction. and hereby au"ve representatives ofthis city no enter upon the
above-mentioned property for inspection purFoses.
PERMIT ISSUANCE. .(o
NIECE IANICAL FEE
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmems, costs adldxpenses which.,,'.yY,� yammarriairinsaid City
in cnnacyuena of ole granting of this ermiI. 0T r
AIR HANDLING UNIT TO 10,000) CPM)
AIR HANDLING UNIT (OVER 111,0110 CFM)
Sig trc of Appli ICo� nor r^�
ate
E%HAUST HOOD (W/DUCD
PAID
HEATING UNIT (TO 100,000 BTU) a
HAZARDOUS MATERIALS DISCLOSURE
- Ume ReceiptN
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
Will the applicant or future building oocupantsrore or handle hrasaous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the I Iealth and Safety
VENTILATION PAN(SINGLE RESIDE �-
-.
Code. Section ❑Y632fa)P Cl No
Will the upplicamorfumre buildingaccupant uxauipmau ordevices whichemir
moues air contaminants as defined by the Buy Arca Air Quality bfanagendent
bima
BOILER- COME)(3HP OR 100,000 BTU)
ISSUANCE DATE
p
A 0
BOILER 1000 BTU)
,00
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
OCT 151993
NEW RESIDENTIAL MECH. SQ. FT.
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
"
ifthe building does not currently have a tenant, than it is my responsibility to notify the
occupant of the requirements which must be mer prior in issuance of a Certificate of
Occupancy.
-" s
c co ur Garen I uvu
ISSUEDBY: Y� f
Ownerorauthmized agent Data
TOTAL: