25490AYYLIUAN I 1 V rILL IN 11'll-UMMA I BJN WI I RIM T1CU LIIYCD - YDC DALE I -VIN 1 ren VIYL 1
CITY OFCUPERTINO BUILDING - ELCTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDEN'DFICA'fION
BUILDINGRE
�//
o ZVADDS �O/ / 'q "EUNIT# LOTM
RS NMN:
jllp'�
CONTRACO NAME: lu LIC
rd117ECT/ENGINFI:R: LIC NO:
ADD UU R- Nir Alto
SU
CONTACT: PHONE:
t�/J/t /) � ,r 7/�`,
r" J a / �• `rc i,/�� �D� �- ���J
9,//
QTY. ELE IC PERMIT
PERMIT ISSUANCE
LICENSED CON'TRACfOR'S DECLARATION
APPLIANCES -RESIDENTIAL
molt
4100
y�
tn60.
Z 0,zA
Olin D
ryt41
q�4 7d
59x6
54iOaU
41Bar�
WC�.E
IL Q p
a �.ff
W_y
Ihcrtbyafflrm thatlam licensed unJerprovisionsof Chaptm9(commenting with
Sation 00(X17 of DivisianJ ofth<Business end Professions Cale, and my license is in
fullI Ice.ndeffim [ 3z 3
License Clan Lic.M� jU a
Date Contractor ,�vQ
CHITECI'SDECLARATION
I understand my plans shall be used as public records.
PANELS
UP T0200 AMPS
201 -IMO AMPS
OVER Ran AMPS
SIGNS ELECTRICAL.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby M. that I am exempt from the Contractor'. License Law for the
following "mxm. (Smile. 7031.5. Businesa and Professions Code: Any city or county
which requires. Pemdt to conxwct, ager, improve, demolish, m repair .ny structure
He, its issuce, also requires the<pplicom far such pm
an eb to fie. signed stmemem
that be is licensed pursuant tome provisions of the Contractor's License law (Chapter
9(commencing withtlection 7") ofDivision 3 ofrhe Business and Profeedians Cade)
or that he is exempt therefrom and the bssis for the alleged exemption. Any violation.(
Section 7031.5 by any applicant for a pemut subjects the applicant to a civil penalty of
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST. '
POW, DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES- FIXTURES
�KK
IC mm
L ..,
more than five hundred dollars (5500).
n❑ Lmmwnerond them eny,mmyempinded oheregnasthei(Sec. 7W.Buation,
will dmhework, end the h.Corciactormendederofwdoesnot.Sec. 20 a4, Business
and Professions Code: The Contractels License Law dens not apply to an owner of
NEW RESIDENTIAL ELECTR _SQ. FT.
pmperrywhobuildsorimprovesthereon.ve who doessuch work himselforthroughhis
ownemployeesilding edthat such proffered for sales If,
rovementhin neyearr
TOTAL:
fo
however, the building ur improvement issold a di inot build ofcomplction, the owner-
Or
builder will have @e burden.( proving that he did not buil) or improve for purpose of
QTY. PLUMBING PERMIT
fie')'
❑ Les.wnerj.t
(Sec. 7 , Business ProfesingwitodcemWeontnetorsto
the project fgtt. oaro Business end Professions CWeO The Cemon, add
License Luwdnesnm apply toanawnmofproperywho builds mimproves thereon,and
License
PERMIT ISSUANCE
whocommulsforsuch Ismimswitb aronnactorp)licensWpartion m the Contractor's
License Law.
ALTER - DRAIN&V[NT - WATER (EA)
❑ 1 am exempt under Sec. . B & P C for this reason
BACK FLOW PROTECT. DEVICE
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND,
WORKMAN COMPENSATION DECLARATION
erehy affirm that l have a certificate ofconsent to self -insure, or a certificate of
.vusmrs Compensation Imumnceor acenifladcopy thermf (Sce. 3800, Lub C.) which
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
covers ell employee's under this permit.
Policy g
Company
GAS - EA. SYSTEM -OVER 4 (EA)
❑ Certified copy is hereby famished.
GREASFIINDUSTRL WASTE INTERCEPTOR
❑ Certified copy is filed with the city inspection division
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20oF7.
(This sectionnadnut becompleted lithe permit is permit, hundred dollars (SIM)
or It
WATER HEATER W/VENT/ELECTR
I certify that in performance of the work for which this permit is issued,Ishail
nos employ any Person in my manner roll-subje§21he Workers
Z
yyQ
F www
l2i Gi
V O
C)
Q 4U1
Cw
V 7
ApplPcanmuory4w xof Cele D _ �O�- YS
WATER SYSTEMITRGTING
NEWRESIDENTIALPLMB. SQ.F"L
NOTICETOEA LICA L.Rer making this Certificate of Exemption, you should
become subject o the Workers Compensation Provisions of the Labor Code, you must
forthwith comply with such provisions .,,his permit shallod deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hen is s construction lending agency for the performance of
the work for which this pemm is I ... ad (Sec. 3N7. Civ. C.)
LenAer's Name
TOTAL:
QTY. MECHANICALPERMIT
Landers Address
certify that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
buildingconstmction, and hereby authodm repo ser atives ofthisciry menter upon she
above-mentioned mopcny, for inspection purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
.^.
(We) agree m save. indemnify and keep harmless the City of Cupertino against
liubilnficyueun g4mrnh��sV.tuddeftpenses wWihrmy in any way sccrue.gainsssaid City
in �rcu�r//"
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
Signature at of Appliccant/Comm ser Date
HEATING UNIT(TO 100,001) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or nature building occupant etomorhandlehawdom material
as defined by the Cup ouran Municipal Cade. Ch.prtr 9.12, and the Health and Safety
HEATING UNIT(OVER IM.OM BTU)
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)R
❑ Yes ❑ No
BOILER-COMP(3HPOR 100,0008711)
/ill thbv licantorfutumbuildin tune tordevices whichemit
PP Boccupen equipmen
BOILER - COMP(OVER IM.00o BTU)
• ous air contaminants as defined by Ne Bay Ara Air Queliry Management
fB
NEWRESIDENTIALMECII. SQ.FT.
0 w 0 N
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code. Sections 25505, 25533 and 25534. I understmd that
if the M1uilding docs nos currently have a tenant, that it is my responsibility m notify Ne
of the mquimmems which moss ed met prim to issumrce of a Certificate of
Occupimt
cupancy.
Owner or authorised agent Date
TOTAL:
PERMIT NO.
25490
SANITARY NO. APPLICATION SUBMITTAL DATE
N/C CONTROL #
FEE BUILDING PGRMIT INFO _
FEE
q,4/4 A/H0UtL-
Al FD IN
13
•� �v/'}mow
, '06 u
FEE SUMMARY
SANITARY Y N
PLANCHECK FEE
GRADING FEE
SOILS ME
ENERGY FEE
PAID
Data Receipt
TOTAL:
BUILDING FEE
SEISMIC FEE
=- ELECTRIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID . f-y�
Data
PAID
AUG 2 51993
CFIY Ur vurcnurvQ
5o