25453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1001L."rin. F.L.CrITMAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 25453
BUILDING PROJECT IDENIIF'ICRI'ION
BUT[fGADDRES& �/�V�,aa , /a� SANITARY NO. APPLICATION SUBMIITAI.DATE
2 I 60 IP��0S UNITp LO'Ik 3
OWNF `NAME �' PHON}iy,q CONTRACTO0.'SN LIC NO:
V NNI/ U NIC CONTROL p
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: 1 ' -
QT4YE,LECTRIC,PERMIT FEE BUILDING PERMIT INFO
MGC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _^ LOB DESC ON
ey.7, Ihercby aRrm Nat lam limnsed undcrprovisions of Chepter9(c�mmencing with
�00 Section]0 of Division 3 of the Business end Prafessims Code,and my license is in PANELS
fL Sb
full force endnd effect.
6 Ly License Clean Lic.N UP T0200 AMPS
on d Dau Connector 201.1000 AMPS
F^yZ ARCHITECTS DECLARATION SQ.FT.FLOOR -.$/SQXr.
O F-,p 1 understand my plans shall be used as public taoNs. OVER ELL AMPS /
OF W SIGNS ELECTRICAL `
Q'" � Licensed Professional I It
� pL6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ��
N�.Oyu Ihercby affirm that 1 em exempt tram the Cantracme.Licere law far Ne
3; following wo�(Samion]031.5.Businus end Nofessions C e:Any city ar county TEMP.METER OR LE ail
tii,
rn5 which requires.permit tocontra,nlup improve,demolish,mrepair any structure
pnortoiuissuance,alsonquiressheapplicantforsuchPemittofileasignednmtemrnt POWER DEVICES
GO that he is licenu4 pursuant to the provision.of the Contractor'.License Law(Chapter
9(comm rang with Section 7000)of Division 3oftha Business and Professions Code) SWIMMING POOL Q-A
�� ��yy VALUATION
or that he is exempt thcrctmm and the basisfor the alleged exemption.Aay violation of �Epg-gWITCTi XIII x / (a
zQSection 7031.5 by any applicant forapewit,.hj.0 Ne applicant me civil penury of ✓,
G re than five hundrud�dolls.($50o). NEW RBSNEN'ITAL EL 5 .FT.
1-7
g0 sownerofthepmpeny,ormyemployeuwithwagesastheirsalecomper 6.n, Q STORIES I TYPECONSIRUCTION
inaotM1ework,and therwemroirnmtimtended araDerca rare.le(sea.]Baa.eaamesa
ad Professions Code:Try.Contractor's License Law does not apply to an owner of
property whobuildsor improves theuon,andwhadoes such workhimulfartluoughhis OCC.
RES.0 ITS
ownempioy<es.pmvidedQvc
mtauch impromcroro
senot intemfedoroficrtdforsile.IL
however,the buildingm improvement is sold within one yearn completion,theowner
builder will hove the burden of proving that he did not build or improve for purpose of
.]a I
❑ I,as ownerofthe properly,amexclusively contracting with licensed contractors to QTYy' - PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7I44,Business and Professions Cade:)The Ciantractm'. PERMIT ISSUANCE
License law dma not apply man ownerof property who builds m impmvea thereon,end
who commas fm such projects withaconuactor(s)licensed pursuant othe Convacmr's �
Licese law.
w.
ppR-DRAIN&VENT-WATER(EA) FEC SUMMARY
❑ l am exempt under Sec. ,B&P C fm this wonDL
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data RT;CIiIPI'M
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercby effiwthaolheve acenificne of consentmself-insure,oracenifcate of FIXTURES-PER TRAP RECEI p
Workers Compensation lnsurmceorocenified copy thereof(Sec.3g00,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS �— RECEI M
PolicyM BUILDING DIVI ON g ES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Ceailled copy is hereby f rmithed.
❑ Certified copy is filed with the city inspection division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This union need Sat be completed ifth.,com is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20pn. :$PAID
GY FEE
err leas.)
I certify that in the performance of the work for which this perdt u issued,l shall WATER HEATER W/VENT/ELECfR
nm employ any person in any murmcr so as m become subject m the Workers'CompareationlawsofCalifornia. Dau WATER SYSTEMIIREATINGO z Applicant0NOTICE TO APMICANT:If,after making ths Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
1 asses I
Ln become subject to the Worker's Compensation provisions of the Labor Cade,you must
; forthwith comply with such provisions or this perdtshall be deemed revoked. DING FEE
CONSTRUCTION LENDING AGENCY MICFEE
z0the work for which this permit is issued(SIL.3(9],Civ.C.) T TRIC FEE r
Lenders Name
LT. PLender's Addsa QTY i{ MECHANICAL PERMIT FEE PLUMBLNG17EE t
rc
L) 1 certify that 1 have reed this application end sou that the information is - lMECHANICAL FF.G
Ge0neco.I Mace to comply with all city and county ordinances and none laws relating m PERMIT ISSUANCE
buildingeonswction,and hereby authorize representatives ofthis city mercer upon the CONSTRUCfIONTA
L) above-mentioned property for inspection purposes. ` ALTER OR ADD TO MECH.
(We)agree m rave,indemnify end kap harmless the City of Cupertino against
]isbdimies.ud,um ,cos LbM 'hmayinanywayaccn�s;ni maid City AIR HANDLING UNIT aO 10,00)CFM)
onmqu ace eg 'ngofthis Wi I pYVjk
IR HANDLING UNIT(OVER IO,000 CEM)
Pic onrawwr ate XHAUSTHOOD OVMUCO
PAID
HAZARDF133US MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dau eceiptN
Will tbcapplicammfutuk building..parishes,handle hazardous meuriel
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,OW BTU) #qL
Code.Sah O YesJ2(a)1 ❑No y VENTILATION FAN(SINGLE RFSID)
BORER-COMP TRIP OR 1110,0011 BTU) ISSUANCE DATE
Will theapplicammfumre G'rildingoccupanmuequipmemordeviceswbich emit BOILER A I D
hemrdous air comentinams as defined by the Bay AreaAirQuality Management BOILER-COMP(OVER 100,000 BTU) r
Dim-ict4 /�
❑YYear ❑Na ,g NEW RESIDENTIAL MECH. SQ.FT. AUG 12 X10 1993
I have read the hazardous materiels requirements under Chapter 6.95 of the w
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that - CITY L1r LUI'CnIIIV
if the building does not currently have a mount,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE
1. 11/16/95 PERMIT INSPECTION ACTIVITY FOR PERMIT # 25453 Page
DATE DONE TYPE OF INSPECTION lu.oector Code PASS/FAIL COMMENT
---------- ------------------------------ ---------- ---- ----------- --------------
INsFEL110 U14 I Luum Y iul
0116/93 FOUNDATION JJ P
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10/21,73 PLBG UIFLR(2ND) JB P
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11/16195 PERMIT INSPECTION ACTIVITY FOR PERMIT # 25453 Page ?
01431 COLUMBUS
DATE DONE TYPE OF INSPECTION Inspector Code PASS/FAIL COMMENT
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