24762APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OFCUPERTINO IIUILLII G-F,LF.C'IRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL,
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
PERMITNO.
gi /I4 �i
L L
BUILDING ADDRIP3S:
SANITARY NO.
APPLICATION SUBMITTAL lUNIT#
LOT if
2— 10—`f3
OWNF]LlNA I. I NE:
CAi — C� C I � -1Y1 !
CONTRACTOR'S E: LIC NO:
awns
N/C
❑
CON'fROLM
AR 1 £C IENGINp FR: IC NO:
109191)/cJeSv(I1 ()L
ADDRESS:
s -M iSYi q verrv0r
CONTACT: PHONE:
QTY. ELHCI'RIC PERMIT' FEE
BUILDING PERMIT INFO
BLD ELECT PLUMB MECH
❑
pC
V`h l I L _ /
PERMIT ISSUANCE
IKZ
100
W E
V V
yy�
LICENSED CONTRACTOR'S DECLARATION
Ihereby aff mthat l am licensed underprovisions of Chaprer9(commencing with
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full farce and effect.
LicenseC s Liap
APPLIANCES - RESIDENTIALTOR
DESCRIt
ION
ABY..
I Q Cm� P W\
PANELS
UP TO 200 AMI .'
I if 101-I M
iQy
Dole
•vZ
y
ARCl11TECTS DEC m TION
1 understand my plans shall he used public records.
MPS
ELECBI
GNS is
�Sp.IT(13A
At
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E/SQ. PT.
J
Licensed Professional
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OWNER -BUILDER DECLARATION
'I hereby affirm But 1 mm exempt from the Commuters License Law fo the
following ration. (Swtinn
to 7031.5, redsodel. Business we,d Professions Code Any city or cn ty
which rcyuires a permit to centrum, aper, impmve, Jemnlish, or repair any at. I e
priarmoit issuance. also rcquims the applicant far sucbpermivafile nsignedswrement
That be is licensed pursuant to the provisions of the Contractor's License Law (Chupor
9(commencingwith Section]W11)of DivisionJoflh,Business rand Pnrfessions Cade)
SPECT CI C LSC.
E
IE P. ER ORP INST'.
PG :R D: PS
>IKIMING POOL ELECIRIC
VALUATION
1—w
GSection
a,in
unbar he is excmpuberefoan and me basis far lhemlleged esemptior Any voutinunofOUTLETS
7131.5 by any applicant for a permit subjects the applicantto a civil penahy of
mme than five hundred Jallurs($5018.
❑ I,osnwneroflM1epropeny, nrmyempinyecswithwegewsiheirselecompe
willdoihework, and the structure isnot intended oroffered forsalicts..] lm
- SWITCHIS- fIXTURFS
NEW RESIDINTIAI. ELECTR S .I°I'.
Q
SIORIBS
'I YPI: CONS] RUCTION
..it PmfO.,mu Coss: The Contractor's License Law dues not apply or an owner of
properly whobulldsor improves thereon, and whodoes such work hlusell'anhmugh his
employees,provi foetal,. If,
earn
OCC.GROUI'
RES. UNI FS
TOTAL:
mpvemenprov,memsarcne
or improvementfoomplleted
however, the building or dmpm provo is sold within one year or improve
omm a for the owner-
hrded). will have the burden nr proving Ihul he Jid not build or improve for purpose of
Q'fY. PLUMBING PERMIT FLEE
❑ I,n roect(Se.7044.mexclusiv
xEl
Cba
FLOOD ZONE
APN
and Poractiore, I'edcommeaorsto
icemaconstruowdoethe p sion (Sec. ]094. Business and Profession Code:I The Contractthrommor's
l.nwdo uun oh who impto and
,
P13RMIT ISSUANCE
sed poor
whor arichapply
a conimalmsy the Contractor's
Licecontracts,w.fu such projects wiNnumvactor(s)IicensW pursuant the Commcmr'e
License law.
ALTER -DRAIN & VENT -WATER (EA)
FEE SUMMARY
❑ I am exempt under sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES
SANITARY Y N
RECEIPT M
Owner Dao
WORKMAN COMPENSATION DECLARATION
DRAINS- FLUOR, ROOP, AREA, COND.
SCHOOL TAX Y
❑ Ibercbyaffrnnhatl huvoaceni0cuto of trmemmtel Ginsurq nal oeniftno of
Workers'Compcnsamion lnsurenceor aceniGedcapythereof(SCc.3g(XI,Iab CJ which
RFCEIITN
p1X'I'URES-PI?R TRAP UD
PARK 1+4311 Y N
GAS - EA. SYSTEM -I INC. OIHLETS
coven all employee's under this permit.
Policy M
RECEIPT M
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (FA)
PLANCIIECK FEE
Cenified copy is hereby famished.
GRFASE/INDUSTRI. WASTE INTERCEPTOR
GRADING FEE
Certified cagy is filed with the city inspection division.
CERT IFICAI'17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRIIASETRAP
SOILS PEE
SEWER.SANITARY - STORM EA. 2(1
ENERGY FEE
(This searmumed not he camplacd ifthe permit is forma, hundred dollars I$ ME
or len.)
WATER BEAT'13R W/VENT/ELECTR
I rectify that in the perf:mmamre of the work for whichthis permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers'
PAID
WNIER SYSTEM/TREATING
NEW RESIDENTIAL PIMB. SQ. FT.
Data ReceiplN
TOTA
Z
Conlpm¢mion Laws of Calililmlu. Dale
Applicant -
NOTICRTOAPPLICANT:If. after making this Certificate of Exemption, you should
(q
became subject to the Worker's Compensation provisions of the Labor Code, you must
5
forthwith comply with such provisions or this pcnmiI shall be deemed revoked.
BUILDING FEE
at
SEISMIC FEE
O
CONSTRUCTION LENDING AGENCY
z
Ilemby aflinn that then lsa conbmctmo lendingagency for the performonee of,
the work for which this p,rmit is ismsul (Sec. 307], Civ. C.)
lander', Name
"✓
TOTAL: ,Z(, ev
ELECTRIC 'ev
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBI s-
D
U
CLcorrect.
IA
z
unify Thal 1 have rend Ibis application and man, that the move infontuliom Is
lagree In romply with ell ciryanJ coumynNinances and amen laws relining to
Wildingcods oution. add herebyawhonae repros,mmivaofmhis caym emerupan be
ave-entioned pmpeny for inspection purpo,es.
ahm
PERMIT ISSUANCE
ALT£R OR ADD TO MECH.
MECH ICAL ME
CONSTRUCTION TAX
(We) agree In save, indemnify and keep hamdess the City of Cupendmo against
habilities,judgmems,cos¢andexpenseswhich may in any way accrue against said City
AIR HANDLING UNIT(TO 10,0010 CFM)
in conseyueme of the granting of this permit.
AIR IIANDLI NO UNI "f (OVER 111,000 CPM)
Signature of Applicant/Contractor Dame
EXHAUSTHOOD(WOUCD
PAID
HHATING UNI f (TO 100,000 BTU)
Date Reccipl
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as def ted by the Cupertino M icipal Csge, Chapter 9.12, and the Health and Safety
Cade, See0on L. Scene.
11 Yes No
TOlL:
I [BATING UNIT (OVER 100,000 BTU)
FAN (SINGLE RESID)
Will the applicnmorfuwm building occupant useequipmentordevices which emit
BOILER - COMP (3HP OR 10 4000 BTU)
UTE
SS A
11ent
BOILER -COMP (DVI?R IOgfYdll BTU)
msSSUAN�E
hNous air commnieants as defined by the Be,Bay Area Air Quality Managem
Dist/RI?
11 Yes 9No
FEBr G 10 1993
NEW RESIDENTIALMF,CH. SQ. FT.
1 have read the havardoms materials requirements under Chapter 6.95 of the
Califomia Health & Safety Cade, Sections 25505.25533 and 25534. I understand that
if the building does not curcedy have promotion it is my responsibility homely the
`` I'�r QF- V UiCr{ 11140
the rcyuirem : which must mm prior to issuance of a Cen.1Te to of
ocupant
ea r e) .
ISSUED BY: 0 G
Owner uulhoriacdagent Data
TOTAL:
OFFICE
t
19765 STEVENS CREEK BLVD
00024762
NEW YORK FABRICS
SCANNED BOX # 739
44
77
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