25529 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BDIr.DTNC-F.I:F.CT1[ICA. PERM]P NO.
BUILDING DIVISION APPLICATION/PERMIT PI.UMBING-MECEIANICAL 25529
-N1111.U1NG PR4a.lE[:'f IDN:N'TIIrICA'1'IfIN _
BUILDING ADDRESS: I SANITARY NO. APPI.ICAA TION SUmirri AI.DATE;
I %O NS'�{/Y Un e— UNIT. LOTa Qy(L
OWNERS NAME: PHONE: CONTRACTOR'S NAME. LIC NO: 1._ {/� {•
� o'Pa an Mil�e� ZSSI3
NYC coNTRol.t
ARCHOECT/ENGINEER:I LIC NO: ADDRESS: ❑
CONTACT: PHONE: i Js Y V'A Ya gy
QTi':t � ` ELECTRIC PERMIT. t 1 'r;�yFEL 7 ' .5 `Elllh$DING$ERMIT TNI O
BLDG ELECT 15 MECH
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWZ Ihemby.ilreadat l amlicensedinderpmvisionsof Chaater9(commencing with JOB DESCRIPTION
woo Section 7")ofDivision 3 of the Business and Professions Cade,and my license is in PANELS
^
FyF�j-�{� full force tied ellen. UP TO 200 AMPS
¢yuy Date cClass Lio.a
v~i 6 y Dwe Gantreelor 201-1000 AMPS ,F7 JJWMM�
ZOyZ ARCIIITELTS DECLARATION OVER LOW AMPS SQ.NT.Il.00R AREA $/SQ.IT.
O y—G 1 understand my plans shall be used as public records.
i'rn� SIGNS ELECTRICAL
YY IiscnbcA lhofcssionel
�CK OWNER-BUILD from
DECLARATION SPECIAL CIRCUIT/MISC.
S5°�'OaU 1 hereby e,affirin(Se that 1 am exempt from the Contractors License Law for the
Ir13LLy¢ following mmoa(Section 7031.5,Business end Rofcssiona Code:Any city.,county TEMP.METER OR POLE INST.
LLJa.I which requires it permit 10 Crushed,their,improve,demolish,or repair any srecpu
P� prior In its issuance.lsoregnircs momplieml mrsuchpernit m file.signed statement POWER DEVICES
w apo that he is licensed pursuantmthe previsions of the Contractors License Low(Chapter
n.a9(commencing with Section 7000)ot'Division 3 ofthe Business and Pmfessiwu Code) SWIMMING POOL ELECTRIC lel < �-„ �. 91 A ATION
ul�m nrthat heis exempt doorman the baspermfortheasegedexemptt to civil
of OUTLETS-SWITCHES-
fIXTtIRES
H 4 mu mil 'ba03 liv5 by any
undredido)[for epemtit subjects the applicannaa<ivil penalty of
nm more that live hundred Jolters($500). NEW RESIDENTIAL ELECTR 5 .
TER I
m ❑ Lasownernfthepropcny,ormyemployaswithwegussthcirsolecampnuadon, Q /Q I" YPI?CONSTRUCTION
n:22 will do the work,and the scartumisnot intendedoro(rend Enable(Sec.]044,Business
and Professions Coda The Contractor's License Law does not apply m an owner of ATE
property who builds orimproves thereon,and who does such work himselfun mmilh his
employees,p building
or
improvement
me OCG GROUP RIiS.UNI'T'S
huwwen the building ur improvement Lasold within oneywo improve for the TOTAL:
afe.) owner-
builder will have the burden of proving that he did not build or improve for purpose of
a�IEJ. e ..y. y . . . . . . .
❑ I,as ownerollheproperty,am exclusively contracting with licensed contractors to QTkY� g ?t tr,1?LUMAING PCRMI'f q TfrF.l FLOOD LONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors -
License,lawdoca not applyro anowneroffamperty whobuildsm improves thereon,end PERMIT ISSUANCE
whocontracts for such projects with acomructons)licensed pursuing to the Cammemr's
License Low. ALTER (IA) FEE SUMMARY
❑ I an exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE. UT ID: E
SANITARY YN
Owner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROUP,AREA,COND, SCHOOL TAX Y_N_
❑ I herebyuffirm that l have acedircaeol'consent toself-insummucenificotc of RECIiIPTa
j/ Wnrkers'CEmpensetion Insurance oracenifiW cnpythermf(Sw.3tlW,lab C.)which IgX1'URES-PER TRAP PARK FEE Y_N
t cuversall employee's..&"his permit. RECF.ln#
GAS-E.A.SYSTEM-1 INC.4 OUTLETS
Policy BUILDING DIVISION F1il3
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumishW.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP SOILS 17EE
COMPENSATION INSURANCE
(This section need not be completed ifthcpcmth is foronehundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the wark for which this permit is issued,i shall WATER HEATER W]VEFIT/ELECIR
not employ any person in any manner sur as to become subject to the Workers' PAID
zCompensmiou Ltwsof tbmM
Celiie. Dare WATER SYSI /IRBATING Recciptis
O Applicant
z NOTICE TO APPLICANT:If.after making this Cenifimmmf Exemption,you should NEWRFSIDENTIAL PLMB. SQ.FT. TOTAL:
t-t 0j hecome subject to the Worker's Compensation provisians afore Labor Code.you must
ai > forthwith comply with such provisions or this femur shall be deemed revoked. BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC PER
z I hereby affil m that hem is a construction lending agency for the performance of
U O the work for which this permit is issued(See,3097,Civ,C.) T TAI. ELECTRIC FEE
4Tap Lenders Name 77 a' ,y t r" au,0
Lenders Address QTMECHANICAL PERMIT "FEPLUMBING FEE?
L
U Y.I cenify that 1 have mad rots application and spur thu the above infomaauE £,: t
acortin.lagramcomplywithallciryarmcounty industries and state laws cited,to PERMIT ISSUANCE MECHANICAL PER,
LoJ building construction,and hereby authorize representatives ofthischy memerupomhe CONSTRUCTION TAX
U "z above-mentioned property for inspection purposes. ALTER OR ADD TO MIeCH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,claim and expenses which mayin any w.yacoreeagainat said City AIR HANDLING UNIT(TO 10.000 CPM)
in asequence of the granting of this permit.
PAER HANDLING UNIT(OVER 10,000 CFM)
a wreof Applican/Contracmr 1bards EXHAUST I IOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant ar I'amre building nccupam smrc nr handle h erurdous mmefiid
as defined by the Cupertino Municipal Code,Chattel 9.12,and the l health and Safety I I RATING UNIT(OVER 100.000 BTU) TOTAL:
Cale,Section 25532(a)? VENTILATION PAN(SINGLE RPSID) •(�
❑Yes 11 No R�I ��1pN�yg
BOILER-COMP(31EP OR 100O00 BTU) DATE
Will the upplicanmrfmurchuilding rkcupam use equipmm ,
en
rdevices which emit
• haaardous air conpminems as defined by the Bay Area Air Quality Managemon BOILER 100,000 BTU)
District? SEP - 9 1993
❑Ycs ❑No NEW RESIDENTIAL MF,CH. SQ.Ff.
I have read the hazardous materials requirements under Chapter 6.95 of the
if the uil Health A,Safety Cedyhave Sections itis my ied 2553�1.
1ityto notify
dthe CI1Y Ur Vurr �
ifthebntof the requirements
which
he thin my reuanceoilirymnficat the
occupant of she reyuiremems which must be mer prior to issuance of o Certificate of
Owner ori vV_ Ys 1
Owner or authorised.gem Dam TOTAL: ISSUED BY:
OFFICE '