25006APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO L 'DING -B R
PI.UM9ING-MF,CHANICAI.
APPLICATION/PERMIT
BUILDING DIVISION r WILDING i'ROJRC'I'IDENTIFICATION
PERMIT NO. ^COO V
L J
BUILDING ADDRESS: JTZ
22�' ln3 a • UNIT# LOT#
SANITARY NO,
APPLICATIONSUBMITTALDATE
OW rRSNAMP.:Atl Welli6l P ON=:
CQVT CI'OR'SNAME: I LIC NO::
N/C
❑
CONTROL#
IRCHITECP/ENGINEER:LIeZNO:
ADDRESS: /
CONTACT: PHONE.
QTY - - ELECTRIC PERMIT FEE
BUR -DING PERMIT INFO
BLDG ELECT PL MB MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby efforts that I am licensed undcrpmvisionsofaapter9(commencingwith
pppLIANCES- RFSIDENTTAI.
JOB DF—SCRIM-10N
Section 9000) of Oivisien3 of the Business and Prnfesaions Code, end my license is in
full force and nlc _ _
u Licens5 #�j 2.95��
iIlam Contractor
ARCHITECT'S DECLARATION
I undemon nd my plmo ,mil be rued as public records.
J
PANELS
UP TO 200 AMPSUJ
201 - 10041 AMPS
OVER 10041 AMPS
SQ. FT. FLOOR AREA S/SQ. FT.
SIGNS ELECTRICAL
j Licensed Professia dd
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 me exempt from the Contractor'a License Law foe the
SPEC IALCIRCUIT/MISC.
TEMP. METER OR POLE INST. I
POWER DEVICES e' s
Cfollowing reman.(Section 0031.5, Business and I'miedons Code: Any city or county
which rsluims u pemit rto construct.
4 et. alter, improve, demolish. or repair any ss
pdnetoitismaam, also reyuiresthe applicant fmamb permit m flea silermOomemem
j That he is licensed Imennunothe provisimem' the Cnntranor'a Licenx Law (Chapter
Ir• ® '
II`L—IN
9(commencing with Section 7000) of Division 3nfthe Hia,mv.eand Professinns Code)
Sectio 7031. by yapplimm for a pesisforbjets thedexempd to civil
• Section 7031.5 by anfiva ndred call.Spermit subjects the applicmuoarnil pencil f
of
hmrorthedreddol.Ormyem1.
SWIMMING Pool, ELECTRIC /A
OUTLETS- SWITCHES - FIXTURE
16— 11VALUATION
q ha
NEW REHDENTIAI, ELECTR S Q'
1no, 1,ma.
❑ L the wrk,and epropeotere onlatcoyeeswifferedorlh wages wilei See 0414.Bsines,
forwileBusiness
will dothewor, and the she
STORIES _
TRUCTION
and Professions Cade: The Convenors
Coreisanemendnce, La do es
Lew does apply to an
apply tort owner of
ndwho
property whces, proarimpmvesthemon,andentsum sauchwmkh .ffmcr Ihroughhis
d
hocmplcyeea,pmvided that suchimprovememsurt not immadeJ proffered forsale. If,
wcvcr, the building orimpervemenl is sold within one yearofmtmpletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
Ie)
❑ I, asawncrofthe propeny,amexclusivdy, contredrngwuhlicenud continuous to
construct the project (Sec. 71144, Business., and Professions Code) Tlm Contractor's
OCC. GROUP
=FLOOD
ERES.NITS
'TOTAL:
TY. -@ i PCUMBINGtPIrRMIT 't jr
Q 'k,: #F'.. d;: J# FEE,'
ZONE APN
License Lew does nm epplymanowncraflroperry eche builds orimpmves lhcmon,and
who contracts forouchprojects with acanwmor(a) licensed pursuant othe Conamemes
License Law.
❑ 1 an exempt under See. , B as P C for this ..an
PERMIT ISSUANCE
ALTER- GRAIN & VENT - WATER (FA)
-"FEE SUMMARY,
BACK FLOW PROTECT. DEVICE
GO SI )I� FEES
SANITARY Y
Owner Dam
DRAINS- FLOOR, ROOF. AREA, COND.
_N
RECEIPT#
WORKMAN COMPENSATIONm3CLARATION
Thereby efOmuhnIlhuvncema0mncof mUdramof(Set.38,or Lab C.) whifificate ofch
`cnvrkers'Compcnsation Insurance oracenified copy lherenf(Sce.3Xm, Lab C.)whicM1
SCHOOLTAX Y N_
RECEIPT
FIXTURES - PER TRAP
PARK FEE Y_N_
GAS -13A. SYSTEM-] INCA OUTLETS
ars all cm lop yr<';yndes.tbu pew iy�y
PolicyN SSM•-jpij_l^a/�) YV
REIVISIO
BUILDINGEVISION FEES
Company yI4
GAS - EA. SYSTEM -OVER 4(IA)
PLANCHF.CK FEE
'❑ Certified copy is term, furnished.
Certified only is filed with me city inspection division.
GREASEANDUSTRL WASTH INTERCEPTOR
GRADING ME
CERTTFICAI'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
(This section malnol be completed ifthe permit is Fortune hundred dollars(SIM)
at less.)
SEWER - SANITANY - STORM b. 20011T.
ENERGY FEE
I reedy that in the perfamanceoftita work forwhich this permit is issued, label
not employ any person in any manner no as in became subject to the Workers'
Compensation larwe of Califomie. Dom
Applicant
WATER HEATER W/VEJNT/ELECTR
WATER SYSTEMaRRATING
PAID e
Dale Recciplp
NOTICE TO APPLICANT, If. oforrmaking this Cenificateof Examption, you should
became subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pround shall he deemed revoked.
NEW RESIDENTIAL PLMIT SQ. FT.
'TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm Ibm there is a oanavuotian lending agency for the performance of
the work for which this permit is Word (See. 3097, Civ. CJ
Le acA Name
SEISMIC FEE
TOTAL: a
ELECTRIC FEE,
Lender's Andreas
QTY.' . MECHANICAL PERMIT- 4FEE'
PLUMBING MR.
1 certify Thal 1 have reed this application and state that the above information is
PERMITISSUANCE
MECHANICAL FEE
enact. l agree to comply with all city and county ordinances and state laws felmingm
building construction, and hereby i uNarize representatives of mis city to enter upon the
abave-mentional property far inspection purposes.
Wed ague to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmema, costs and expenses which may in any way acme against said City
consequence of the grunting of this lu mtit.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO BLOW CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
Siloomre of APPlicant/Cnntracme Data
EXHAUST HOLD(W/DUCq
PAID
HEATING UNIT (10 100.000 B'T'U)
HAZARDOUS MATERIALS DISCLOSURE or handl
Will or buildingoccupantatomor
Date Receill#
TOT
the Cupeant
Munture amdkhe am and
as Jcfincd by the Cupcnino Municipal Code. Chapter 9.12. mJthe Ham and Safery
Cale, Section 25532(a)9
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
❑Yes 0 N
BOILER - COMP DHP OR 100,0041 BTU)
ISBAUNe DATE
�#''YY II
Will Neepplicmmrfumrtbuildingaccupanwsecquipmem nrdevices whichemit
hazardous air contaminants as defined by the Bay Area Air Quality Management
Dixtnntl
BOILER 100,00013TU)
❑ Yes ❑ No
1 have read the hiorardous amenab requiremmta under Chapter 6.95 of the
Culifamiu Health &Safety Code, Sections 25505,25533 and 25534, l understand that
if the huilding dswa nm curzently have n mnanL lhm it is ery responsibility m notify the
occupant of the rtquiremetns which must h met poor to issuance of a Certificate of
Oompmcy.
j
/s >Ju I" 1993
C1/ y
LIM
BY: '
NEW RESIDENTIAL MECH. SQ. FF.
Owner or nmhnrreN agent - Dnle
TOTAL: ISSUED