25829APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CIDP
APPLICATION/PF,RMIT
... - mAl.
PLUMBING -MRCHNT]IgC
PERMIT No.
DIVISION
BUILDING DIVISION
,BUILDING PROJECT' IUEN'1lIHCA'ITON .
BUILDING ADD�Rf`ESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
�(/J ��♦
� O `J! � \WI dale OA Z Cr
UNIT# LOT#
L
OW QRS NAME: PHONE:
CO fRACTOR'S NAME: LIC NO:
NIC
❑
CONTROL#
vl Il ,E 'f �, 4i'l32
IARCHIIECI'BNGINEER: LIC NO: ADD SS: lr-PlIttMa� VE UYALG Cfa
'CONTACT: PHONE:
''K#'='A '141f 5.'„'p3 ag(x^eaTs +', {.yr
":+c ick
. , BUILDING•PERMIT INFO '
Q71Yi E IFOTRIC.PERMITN $ ; r FEC €
' p
. BLDG ELECT PLUMB MUCH
I P
PERMIT ISSUANCE
El N9b
ED1-1
CONTRACT'OR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DESCRI ON
Ibercb [firm that licensed under
hereby pro (commencing with
j Section 7000) of Division of the Business and Professions Code, end my license is in
Professions
PANELS
Intl d effect.
Licensense ClaClass Lic.#
UP T0200AMPS
Dam Convector
201 - 1000 AMPS
?j ARCHITECTS DECLARATIONOVER
11X10 AMPS -
SQ. lef. FLOOR AREA
$/SQ. En
I understand my Plums shall be used os public records.
0
SIGNS ELECTRICAL
Licensed Professional
OWNER.BUILDER DECLARATION
SPECIALCIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contractor's License Law for the
reason. (Section 7031.5, Businessland Professions Code: Any city or county
TEMP. METER OR POLE INST.
Sfnlbwing
which requires a permit to construct, alter, improve, demolish, a repair any structure
e prlono ire Lssuwce,alsodomfics the applicant forsueh permit to file. silledstatanent
POWER DEVICES
j That he is licensed pursuant to the provisions of the Contactors License Law(Chapter
9(commeneing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
p p� TION
orthat he is exempt therefrom and the basis for the alleged exemption. Any violation of
I,
IIS II;L—®
CSection 7031S by any applicant for a permit subjects the applicarn to a civil penalty of
OUTLETS - SWITCHES PIXTURFS /I'1
> nrt ml,asom aan five hundred ,
❑hppen
NEW RESIDENTIALELECTR ��
'f
wnerof eolorsmyem
ployeeswithwagesasthelrsolee mpensation,
will Codec nobs opl,an Business
_SQ. . 1
1 T PE CONSTRUCTION
Prohe fessions Law does not apply t
s
and Professions Calm The Co
he Contractor's License
License Law does not apply to an owner ofpro�
_
'
there's
comenywyars, pedviimproveeb impar ementedoessuctende oroffredthrside.Is
vementsan not intended fionthea elf,
entr,
_ - RES, UNITS
however, the
thees,pingor i provement is
r improvement is sold within one year or t r -
have the b proving P Purpoeeo
improve for purpose
bale.). will have the burden of in that he did not build or improve for f
TOTAL:
sale.).
wx4 BY Y Y- Fza yy '>'- .
FLOOD ZONE APN
F2
❑ I as owner effm oa en Iusivel contracting QTY. *,PLUMBING PERMIT^ n p_FEE�„ t
P P Ynm oxo y gwtthllcensedconvacmm to t#X. ��T{a a,¢„y♦
construct the project (Seo. 7044, Business and Professions Code:) The Contractors
if
License Law does not apply manowneraThoperty whobuildsorimprovesthenon,and
PERMIT ISSUANCE
whoamtrmts for such projects with acmnvaemr(s) licensed pursuantm fie Contractors
License Law.
WATER CA
ALTER ( )
-
r t _ r FEE -SUMMARY
❑ lam exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
II I MOF FEE
Owner Dete
SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARON
DRAINS - FLOOR, ROOP,ARM, COND.
SCHOOLTAX Y N
❑ I hereby afford that l have a certificate ofconsenuo self-insure,mil certificate of
FIXTURES - PER TRAP
RECEIPT#
PARKME Y Nom_
er
Workers' Compensation Insurance a certified copy hereef(See. 3800, Lab C.) which
I
a re all employee's under Nie permit
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
I1O1'#
hum my
of ified copy is hereby furnished.
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified copy is filed with the city inspection division.
CREASEdNDUSTRL WASTE INTERCEPTOR
GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
. COMPENSATION INSURANCE
(This section incident he completed ifhe permit is former hundred doll.($Udd
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
orless.)
I certify that in the performance ofthe work for which this permit is issued, I shall WATER HEATER W/VENT/ELECTR
not employ any person in any mother so as to became subject to the Workers'
PAID
Cnmpenation Lawsof Califomla. Date
WATER SYSTEMUREATING
Date Recoiled
Applicant
NOTICE TO APPLICANT: If, after making this Cmificlle of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. PP.
TOTAL:
become subject o the Workers Compensation provisions of the Labor Cade, you must
BUILDING FEE
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
ELECTRIC FEF
the work for which this permit is issued (Sec. 3097, Civ. C.)
Leader's Name
-
bendersAddress
QT1fg p'^MeCIiANICAT3PERMIT '`PPE=
PLUMBING FEE r
1 comfy that 1 have road fits and slate that the above information to
.-
h,ar.,tsrr4Ga 'a*.,a r+„T`.xe„
MECHANICAL FEF,
rect.lagrr, with city and county seadn
age PERMIT ISSUANCE
cauntyntativsof Cndity
inityand
a .andmply
nsvuetioo,and herebyimpecion initiative of hincity roemermpon the
to nform
CONSTRUCTION TAX
idawcngc
.hove- tiered property for inspection purposes. ALTER OR ADD TO MECH.
e) agree to save, indemnify and keep harmless the City of Cupertino against
,judgmems, costs andexpensm which may In my way accrueegaNhsald City AIR HANDLING UNIT(TO 10,000 CFM)
gond t 's p It.
41tabi
1I- _ / a AIR HANDLING UNIT(OVER IQ000 CFM)of
App e,Y ohtredor en •(
EXHAUST HOOD(W/DUCT)
,
!l
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Data Receipt#
Will me applicant or future building oeeupam store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
f1EAT1NO UNIT (OVER 100,0(h) BTU)
Code, Section 25532(n)?
❑ Yes ❑ No
VENTILATION FAN (SING LF RESID)
Willeea licant nr fumrebuildin p quipmen
pp gby
amuse¢ muality
BOILER - COME (3HP OR IOO,WU BTU)
IA�gUANGE DATE
P 1AUAW
us air contaminants as defined by the Bay Area Air Quality Management
t Management
Di,obt
Disvih'1
BOILER - COMP OVER 100,000 BTU
( )
❑ Yes 11 No
DEC1
C ” 91993
NEW RESIDENTIAL MECIL SQ. Ef.
-
1 have read the hazardous materials requirements under Chapter 6.95 of the
W
California Health & Safety Code, Settlors 2.5505, 25533 and 25534. 1 understand that
CITY ur uurtH
if the building does not cl really have a found,, met it is my responsibility to notify the
I t1yu
occupant of the requirements which must be met prior to issuance of a Certificate m
Owor
ISSUED BY: v ✓' , l
ner or authorized
Owner agent Date 'TOTAL:
0"ICE