25639APPLICANT TO FILL IN INFORMATION WITHIN RED LINEs - HRE Rel I OiIIMT OOM (Moll V
CITY OF CUPESION
PERMITNo.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING - MNCHANICAL
w
L b
NUILDING PNOJF.CI' IDENTIFICATION
B39
WILDING ADDRESS:
�03�3 G'o��yq,t a iii/G�//uQ
SANITARY NO.
APPLICA�TIO�N^%SUgBIMS�f{•ITA^L`DATE
UNIT. LOT
�0 _V Y/
OWNERS NA F.: ^ / PHONE:
epn S
CONTRACTOR'S NAME: LIC NO:
N/C
CONTROL it
L.� t/FZ11LA 'r ZJ-2 — O/ ALG% S, LAN/L/ ,�
RCHITECI'/ENGINEER: LIC NO: ADDRESS:
❑
CONTACT: PHONE:
`r,
QTY. =�I; ELECTRIC PERMIT
. ..;•
"FEE
BUILDING PERMIT INFO
ELECT PLUMB MECH
-� r.. . '
PERMIT ISSUANCE
wyl-1�� F-1 ID E]LICENSED
CONTRACTORS DECLARATION
L Iherebyaffinn that lam licensed under provisioaofChapmr9 (commencing with
APPLANCTS- RESIDENTIAL
JOB DESCRIPTION
J Section70W)af Divixiun 3 of the Business and Profusions Code, and my liceae is in
PANELS
Fall force and effect,
n�
Y License Class Lic.p
UP TO2W AMPS
1/
Data Contrwtm
201 - IOW AMPS
L - ARCHITECTS DECLARATION
1 un lmsband my plans shall be used as public records.
OVER 1000
SQ. PT. FLOOR AREA
E/SQ. Pf.
RICAL
^^
LrccaN Professroal
I
OWNER -BUILDER DECLARATION
I hmby affirm that 1 am exempt from the Contractors License Law for the
INIMIS .
�'following
-,
reason. (Section 7031.5, Business and Professions Code: Any city or county
OR Po MST.
which requires a permit to construct, site', improve, demolish, or repair any swcture
KSPECiAL
its issuance, alsorequims the applicant fienoch permit to file a signed statement
_pdorto
ES DAIS24
that he is licensed laroman in the provisionof the Contmease. Littnw law (Clupmr
9(commencing with Section 7000) of Division 3 of the Business and Profusions Cade)
OOL ELE
VALUlsl,2�MM
or that he is exempt therefrom and the basis for the alleged exemption. My violation of
7031.5 by wry applicant for a permit subjects the applicant a civil penalty of
ITCHES -FIXTURES
��(-`Section
not more than five hundred dollars ($5W).
❑ I,asownerofthcpropenyormyemployeeswith wagetastheirsolecompemation,
NEWRPSIDENTIALELECTR_SQ,FT.
STORIES
TYPECONSTRUCfION
will dothe work, and thestructure is not imeadedoroffered forsale(See. 7044, Business
and Professions Code: The Commuter's License Law does not apply to an owner of
pmpeny whnbuildsorimproves themumandwhodoessuch workhimselfor Buough Ns
sun employees,provided thauuch improvements sum not intendadoroffeind Porsale.If,
OCC. GROUP
RES. UNITS
however, the bulldingor improvement is sold within one yearof completion, the owner -TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sola).
❑ I, asowncrof the property, smexclusively contracting with licensed counterman, QTY.PLUMBING PERMIT
FEE
FLOOD ZONE
APN
mnsuuct the project (Sec. 7Dt4, Business and Professions Code) The Contractor's
License Law does not apply 10 an owner of property who builds or improves thereon,and
PERMIT ISSUANCE
who common, fimmeh projects withecontrstmr(s) licensed pursuant m the Contractor's
License Law.
ALTER- DRAIN&VENT - WATER (HU
FEE SUMMARY
❑ 1 em exempt under gee. , B & P C for thio mown
BACK FLOW PROTECT. DEVICE,
OUTSIDE
Owner Dam
SANITARY YN
RECEIPI'p
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOL TAX Y_N
❑ I hereby affirm that l have a cmificate of consent selGinsure, or a wtificate of
RECEIPI'p
Wmken%ComN=tionlnsurenceoraceniFiMc ythereof(Sm,3WC,.Ub C.)whichE
FIXTURES PER TRAP
PARK FEE
torsos all employee's under this permit
Policy M
GAS - EA. SYSTEM-] INC. 4 OUTLETS
V N
RECF,IPT p
BUILDING DIVISION FF
Company
❑ CenificJ copy in hereby famished.
GAS - EA. SYSTEM OVER 4 (EA)
PLANCHECK FEE
❑ Ceni0rd ropy iv fled with the city inspection division.
GRADING FEE
GREASFJINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS
COMPENSATION INSURANCE
FEE
(This section need net be completed ifthe permit is for one hundred dollan(SIW)
SEWER - SANITARY - STORM EA. 2WFT.
ENERGY FEE
orless.)
I cenify that in the perfomunce of the weak for which this Permit is issued,)shall
WATER HEATER W/VEJJT/ELECTR
not employ any Amon N any mumer w to to become subject to the Worker
CAoo 'tion Lswsof Califomiw Dom
WATER SYSTEMORE.ATING
PAID
Dom
Receix If
NOTICE TO APPLICANT: IC after making this Certificem of Excon own, you should
NEW RESIDENTIAL PLMB. SQ. FT.
become subject to the Workers Compensation provisions of the labor Code, you must
TOTAL:
forthwith comply with such provisions or this permit shall be deemed invoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE t
I hereby affirm that there is a construction leading agency for the performance of
ELECTRIC FEE
the work for which this permit is issued (Sec. 3097. Civ. C.) TOTAL:
Lender's Name
-
lsnders Address QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
I cenify that 1 have reed this application and state that the above information is
MECHANICAL FEE
camsetlagrtetocomplywith all city aMcountymdinartwand smtelawarelatngue PERMIT ISSUANCE
building construction, and hereby authmise repinsentmoesofthiscity toenterupon the
CONSTRUCTION TAX
abov-memioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wa) agree in save, indemnify end keep harmleas the City of Capertim shouter
liabilities,judgmenta,costs endexpe swhtchrayinany waywerueagelnstsau City AIR HANDLING UNIT (TO Hit" CFM)
iric se oft egr ting f is
/0, ley AIR HANDLINGUNIT(OVER 10, 000 CFM)
Slgnaure of AppheanVCommet I a
EXHAUST HOOD(W/DUC7O
PAID
BAZAR S MATERIALS DISCLOSURE
HEATING UNIT (TO 100," BTI/)
Date R<ttip #
Will the applicant or future building occupant store ne handle haerdons material
u defined by the Cupertino Municipal Code. Chapter 9,12, and the Health and Safely
HEATING UNIT (OVER HX)JM BTU)
TOTAL:
Code. Section 25532(a)T
EI Yea El No VENTILATION FAN (SINGLE RESID)
Willtheecoution to Tatumbuilding occupant use eyuipmcnmuality es which emit
BOILER- COMP(3HP OR IWJ000 BTU)
IS E
heaallous air contaminants as defined by the Bey Arae Air Quality Management
°`a""' ❑ Yen ❑ No
BOILER - COMP(OVER IWOOBTU)
OCT 16 1993
NEW RESIDENTIAL MICH. SQ T
r♦
1 have mad the hamNous materials requirements under Chepttt 6.95 of the
4r /a'11 r •s
California I leulth & Safety Code, Sections 25505, 25533 and 2553,1 I understood that
H 1 1 Vu F,LIY m Itav
if the building docs not curremly haven moat, thin it is my responsibility to notify the
occupant of the requirements which must be met prior m issuance of a Certificate of
Occupancy.
ISSUED Bl'�/LAII� ► /
Owner or amhanud ahem Data TOTAL:
urrlG,t