25287APPLICANT TO FILL IN INFORMATION WITHIN am I lure _ seer mAr r
CITY OFCUPE
BUILDINGDIVISION APPLICATION/PERMIT
PLUMBING - MF.CHANICAI.
PERMIT No.
25287
II UILIfING PROJECT IDENTIF]'CAT ION
UNIT# LOT#
CONTRACTOR'SNAMEE CMO:
BUILDING ADDRESS: //�ke�ao�1111
y ;'J.�s/q JN N
�J 6 �#/M/tlj M"/ Y ,h6 ^Q
UWNERS AM PHONE:
LID
SANITARY NO. APPLLCATI/ON SUBMITTAL DATE
�.�6
((JJ
a5>65
' ARCHITECT G LI NO:
—
ADDRESS:
NC CONTROL#
El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT P U B MECH
❑ ❑ p. ❑
PERMIT ISSUANCE
LICENSED CONdundaPR'SionsofDECLARATION
.Z thembyml nan Disihatlnmfthe edunswreal rifesio Chapter and my ficame with
10 S it Irm ]1100) of effect. on J of the Buaineea end Professions Code, end my limine is in
I full force and effect. r
APPLIANCES MMEN7AL
PANELS
JOB DFSCOFHON
License Class
y Dom Contramm
M TO 200 AMPS
1
r Z 'ARCHITECTS DECLARATION
! G 1 understand my Plass shell he used u public records.
201 - 1000 AMPS
OVER 1003 AMPS -
SQ. FT. FLOOR AREA
!i/SQ. FT.
SIGNS ELECTRICAL
Licensed Proferoad
U OWNER -BUILDER DECLARATION
1 hereby affirm Nat 1 an exempt from the Commctols License Law for the
oaii following reason. (Section 7031.5, Business and Professions Code: My city or county
J which "ui= a permit to construct. alter, improve, demolish. or repair any smacmre
Prior to its issuance, also requires the applicant forauch permit to file a signed statement
p that he is licensed pursuant to the provisions of the Coatmm.rs License Law (Chapter
R' 9(commencing with Section 700B of Division 3 of the Business road Profusions Cade)
W or that he is exempt therefrom and the basis Me Be alleged exemption. My violation of
Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
than five hundred doll., ($500).
s owneroftheJanuary, army employees with wages u dui, sole compensation,
ework.andthestmcwu isnotinwndedoroffemdforsale(Sec.7044,Businue
Iessions Cale: The Contmmor's License Lew does not apply to an owner of
who builds., improve do nam, and who does such work himselfor through his
ow if. thaeuch improvememsem notimendedoroRered forsde.if.
, the building mimprovemem is sold within one yearofc-didetion, thematic,
rbuildffill have the burden of proving that he did not build or improve for purpose of
wile.).
SPECIAL CBICUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW'RCSIDENTIALELECIR _SQ,,T.
STORIES
TYPECONSTRUCTION
OCC. GROUP
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
[I 1,asownerofthepropeny,amexclusiva]ywnnectingwimlicensmcununctorsto
.mmuct the project (Sec. 7044, Business and Profesimm Code:) The Can..,',
License Law does not apply to an owner OTeopeny who builds or improves Merton,and
who commas for such Pori with a commuemr(s) lieeaeed pursuant to the Contractor's
License Law.
❑ 1 not exempt under Sec. , B & P C fm this reason
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
O 1 E
Owner Dam
SANITARY y ry__
RECEIPT#
WORKMAN COMPENSATION DECLARATION
' ❑ Ihercby affirm the l have ac -it'. ofco...... If-insu
Wmknn Comho anion Insurance orocerificd copy thereof(Sec.3A03,LabC)which
covers all employee's under this pmmit
Policy Of
DRAWS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX Y N_
RECEIPT#
FIXTURES -PER TRAP
PARK FEE Y __N
RECEIPT #
BUILDING
GAS - EA. SYSM-M-1 INC. 4 OUTLETS
Company
GAS - BA. SYSTEM -OVER 4 HA)
DIVISION HIS
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
EXEMPTIONMOMWORKERS'
CENTIFICATE OFOMPE COMPENSATION
COMPENSATION INSURANCE
PLANCHF.CK FEE
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
GREASE TRAP
SOILS FEE
(This section rued not be completed if the permit is for one hundred dollars
or IessJ
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE
I certify than in Neperformenu Ofthe work fm which the permit is issuc.I abs,
not employ any personamma
in any mso as to become subject to the Workers'
Compensation Lowsof Califo
APPiiOnt mia. Date
WATER HEA'IFR WNFM/ELECIR
PAID
Dae Receipt#
WATER SYSTEMRFATING
R
NOTICE TO APPLICANT: If, seba making this Cerifiate of Exemption, you should
become subject to the Worker's Compensation provisions of Ne Labor Code, you must
forthwith comply with such provisions or this permit shell be deemed revoked.
NEW RESIDENTIAL PLMB. SQ. PI'.
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfi mume of
the work for which this permit is issued (Sec. 3097, Civ. CJ
lender's Name
SEISMIC FEE
TOT
ELECTRIC FEE
Lend Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify
eerily that I have mad this application and state that the above information is
corrst lagrs to comply with all cityeM wunry ordinance end cum laws relating to
building construction, and hereby authorize representatives alibis city to enter upon Ne
above-mentioned property for inspection purposes.
(We) agrce no save, indemnify and kap heamleu Be City of Cupertino against
liabilitiesend entacuuondexpmuswhichm no any wayamrueagainst said City
in conseyucnceof the gmntiof thix perm
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
GDNSTNHCTIQN TAX
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (0 10.000 CFM)
ppiiemilCmumet., Data
EXHAUST HOOD(W/DUCT)
IIAZARDOUS MATERIALS DISCLOSURE
epplicam or future building oecap., score or handle hazardous materiel
PAID
Data Receipt#
HEATING UNIT(TO 100,030 BTU)
T
7deflacd.lonandind
he CupertinolonandWl Code. Chapter 9.12, and the Health and Safety
25532(q?Yes
HEATING UNIT (OVER 103,000 BTU)
VENTILATION FAN(SINGLE RESID)pplicantor
❑No
future building necupent use aqui
#anent ordevicu whichemitconuminams as defined by the Bay Arm AU Quality Menegement
District?
BOILER - COMP QHP OR 100,000 BTU)ISSUANCE
BOILER- (
COMP OVER 103,000 BTU)
DATE
pp pp
Y' M I U
❑ Yes ❑ No
NEW RESIDENTIAL MECIi. SQ. FT.
1 have read the hazardous cool als requirements under Chapter 6.95 of the
Califomie Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building doe not curently havers tenant, that it is my responsibility to notify the
occupant Of the requirements which mea he at prim m issuance of a Ccrificare of
Occupancy.
JUL - 6 1993
/�
V I I i Ur VUI"Ln I ITV V
BY f
Owner or amhorized again pine
TOTAL: ISSUED
APPLICANT TO FILL IN INFORMATION WITHIN am I lure _ seer mAr r
CITY OFCUPE
BUILDINGDIVISION APPLICATION/PERMIT
PLUMBING - MF.CHANICAI.
PERMIT No.
25287
II UILIfING PROJECT IDENTIF]'CAT ION
UNIT# LOT#
CONTRACTOR'SNAMEE CMO:
BUILDING ADDRESS: //�ke�ao�1111
y ;'J.�s/q JN N
�J 6 �#/M/tlj M"/ Y ,h6 ^Q
UWNERS AM PHONE:
LID
SANITARY NO. APPLLCATI/ON SUBMITTAL DATE
�.�6
((JJ
a5>65
' ARCHITECT G LI NO:
—
ADDRESS:
NC CONTROL#
El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT P U B MECH
❑ ❑ p. ❑
PERMIT ISSUANCE
LICENSED CONdundaPR'SionsofDECLARATION
.Z thembyml nan Disihatlnmfthe edunswreal rifesio Chapter and my ficame with
10 S it Irm ]1100) of effect. on J of the Buaineea end Professions Code, end my limine is in
I full force and effect. r
APPLIANCES MMEN7AL
PANELS
JOB DFSCOFHON
License Class
y Dom Contramm
M TO 200 AMPS
1
r Z 'ARCHITECTS DECLARATION
! G 1 understand my Plass shell he used u public records.
201 - 1000 AMPS
OVER 1003 AMPS -
SQ. FT. FLOOR AREA
!i/SQ. FT.
SIGNS ELECTRICAL
Licensed Proferoad
U OWNER -BUILDER DECLARATION
1 hereby affirm Nat 1 an exempt from the Commctols License Law for the
oaii following reason. (Section 7031.5, Business and Professions Code: My city or county
J which "ui= a permit to construct. alter, improve, demolish. or repair any smacmre
Prior to its issuance, also requires the applicant forauch permit to file a signed statement
p that he is licensed pursuant to the provisions of the Coatmm.rs License Law (Chapter
R' 9(commencing with Section 700B of Division 3 of the Business road Profusions Cade)
W or that he is exempt therefrom and the basis Me Be alleged exemption. My violation of
Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
than five hundred doll., ($500).
s owneroftheJanuary, army employees with wages u dui, sole compensation,
ework.andthestmcwu isnotinwndedoroffemdforsale(Sec.7044,Businue
Iessions Cale: The Contmmor's License Lew does not apply to an owner of
who builds., improve do nam, and who does such work himselfor through his
ow if. thaeuch improvememsem notimendedoroRered forsde.if.
, the building mimprovemem is sold within one yearofc-didetion, thematic,
rbuildffill have the burden of proving that he did not build or improve for purpose of
wile.).
SPECIAL CBICUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NEW'RCSIDENTIALELECIR _SQ,,T.
STORIES
TYPECONSTRUCTION
OCC. GROUP
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
[I 1,asownerofthepropeny,amexclusiva]ywnnectingwimlicensmcununctorsto
.mmuct the project (Sec. 7044, Business and Profesimm Code:) The Can..,',
License Law does not apply to an owner OTeopeny who builds or improves Merton,and
who commas for such Pori with a commuemr(s) lieeaeed pursuant to the Contractor's
License Law.
❑ 1 not exempt under Sec. , B & P C fm this reason
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
O 1 E
Owner Dam
SANITARY y ry__
RECEIPT#
WORKMAN COMPENSATION DECLARATION
' ❑ Ihercby affirm the l have ac -it'. ofco...... If-insu
Wmknn Comho anion Insurance orocerificd copy thereof(Sec.3A03,LabC)which
covers all employee's under this pmmit
Policy Of
DRAWS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX Y N_
RECEIPT#
FIXTURES -PER TRAP
PARK FEE Y __N
RECEIPT #
BUILDING
GAS - EA. SYSM-M-1 INC. 4 OUTLETS
Company
GAS - BA. SYSTEM -OVER 4 HA)
DIVISION HIS
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
EXEMPTIONMOMWORKERS'
CENTIFICATE OFOMPE COMPENSATION
COMPENSATION INSURANCE
PLANCHF.CK FEE
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
GREASE TRAP
SOILS FEE
(This section rued not be completed if the permit is for one hundred dollars
or IessJ
SEWER -SANITARY -STORM EA. 200FT.
ENERGY FEE
I certify than in Neperformenu Ofthe work fm which the permit is issuc.I abs,
not employ any personamma
in any mso as to become subject to the Workers'
Compensation Lowsof Califo
APPiiOnt mia. Date
WATER HEA'IFR WNFM/ELECIR
PAID
Dae Receipt#
WATER SYSTEMRFATING
R
NOTICE TO APPLICANT: If, seba making this Cerifiate of Exemption, you should
become subject to the Worker's Compensation provisions of Ne Labor Code, you must
forthwith comply with such provisions or this permit shell be deemed revoked.
NEW RESIDENTIAL PLMB. SQ. PI'.
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfi mume of
the work for which this permit is issued (Sec. 3097, Civ. CJ
lender's Name
SEISMIC FEE
TOT
ELECTRIC FEE
Lend Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify
eerily that I have mad this application and state that the above information is
corrst lagrs to comply with all cityeM wunry ordinance end cum laws relating to
building construction, and hereby authorize representatives alibis city to enter upon Ne
above-mentioned property for inspection purposes.
(We) agrce no save, indemnify and kap heamleu Be City of Cupertino against
liabilitiesend entacuuondexpmuswhichm no any wayamrueagainst said City
in conseyucnceof the gmntiof thix perm
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
GDNSTNHCTIQN TAX
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (0 10.000 CFM)
ppiiemilCmumet., Data
EXHAUST HOOD(W/DUCT)
IIAZARDOUS MATERIALS DISCLOSURE
epplicam or future building oecap., score or handle hazardous materiel
PAID
Data Receipt#
HEATING UNIT(TO 100,030 BTU)
T
7deflacd.lonandind
he CupertinolonandWl Code. Chapter 9.12, and the Health and Safety
25532(q?Yes
HEATING UNIT (OVER 103,000 BTU)
VENTILATION FAN(SINGLE RESID)pplicantor
❑No
future building necupent use aqui
#anent ordevicu whichemitconuminams as defined by the Bay Arm AU Quality Menegement
District?
BOILER - COMP QHP OR 100,000 BTU)ISSUANCE
BOILER- (
COMP OVER 103,000 BTU)
DATE
pp pp
Y' M I U
❑ Yes ❑ No
NEW RESIDENTIAL MECIi. SQ. FT.
1 have read the hazardous cool als requirements under Chapter 6.95 of the
Califomie Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building doe not curently havers tenant, that it is my responsibility to notify the
occupant Of the requirements which mea he at prim m issuance of a Ccrificare of
Occupancy.
JUL - 6 1993
/�
V I I i Ur VUI"Ln I ITV V
BY f
Owner or amhorized again pine
TOTAL: ISSUED