25163APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
APPLICATION/PERMIT P1NU
CITY OF CUPERTINO tlU11.0
BUILDING DIVISION ;PROJECTIDENTFICATION
PERMIT NO.
1 O
BUIIL%DIN(G�A'DDDRREE4SSS:
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LOT p
O" 1 a T W 1 I / e O I� UNI�T�pR/
SANITARY NO.
AP MICATIONSSUBMIITTTALDATE
l/ C
OWN RSV17�i uJ� 6 bar PH� —
ME:
C�\/ r GS�1 II lir... J afiN /JU 6
N/C
❑
CONTROL #
AgSF11TErGI(JIjHill g� LIC NO:
�rjj 1111 VV 1\
ADDglif$_� ,�/4 �� r J - ` r
CONTACT: PHONE:
N 1 pviin_ 9 / 9 V
-T�`•'A
QTY. '/ ; • x ELECTRIC PERMIT FEE
..
BUILDING PERMIT INFO
BO ELECT PLUry1B MO1
PERMITISSUANCE
LICENSEDCONTRACTOR'SDECLARATION
1 hereby off. thatl amlicensedunder pmCh
visionsofep erg (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
a
Smims7000)of Division 3 ofthe Business and Professions Cade, and my license is in
full force and effect.
License Clens Lic.#
PANELS
UP TO 200 AMPS
Dam Co.,., r
20 1 - 1000 AMPS
W V
ARCHITECTS DECLARATION
1 understand my Plana shalt be used m public records.
OVER 1000 AMPS
SQ. FF. FWOR AREA
SISQ. FT.
SIGNS E-LECDUCAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIALCIRCUTIMtSC.
I hereby affirm that 1 not exempt from the Contractors License Law for the
TEMP. METER OR PULE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which reqit m requires a permconstruct, alter, improve,ir demolish, or repaany awcture
primp, missuance,.k. remiss heupplicant for such pesmiuo fileasigned sutement
IN
POWER DEVICES I
�`
that he is licensed pursuant to the provisions ofthe Convectors License Lew (Chapter
9(commencing with Section7U0tt) of Division 3 ofthe Business and Professions Code)
or he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by tray applicant for a permit subjecm toe applicant m a civil penalty of
SWIMMING POOL ELECTRIC /
f' VALUATION
t,
OUTLETS-SWITCHES-FlXTURES
not more than five hundred dollars (5500).
❑ I,asownerofiMe opwy,mmyemployeeswlNwagamtheirsolecompensation,
T
NEWRESIDENTIALEI.ECTR
TYPECONSTRUCIION
will dothe wmk,sod the svunurois not intendedoraffered formic ESm.7044, Business
and Professions Code: The Contra tro's License Law does not apply to an owner of
property whobuildsorimproves thereon, and whodoessuchwark himxlforthmughltia
ownemployces, provided that such improvements art not intended moRered particle. If,
OCC. GROUP
RFS. UNITS
TOTAL:
however, the building mimprovement is sold within ons yearofcompletion, disown'-
builder will have the burden of proving that he did not build or improve for purpose of
QT}"' PLUMBING PERMIT FEE
sale.).
❑ 1.uowneroftheproperty,mcxclavvelycommclingwithlicensedwnu=Wmio
FLOOD ZONE
APN
omtmct the project (See. 7044, Business and Professions Code:) The Convector's
License Law does not apply to an owner ofpropeny who builds or improvestheraon,antd
PERMIT ISSUANCE .Q
who contracts for such projects with acontmmm(s) licensed pursuant an the Contractors
License Law.
ALTER - DRAIN&VP,NT - WATER (FA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C fm this mavenOUT
BACK FLOW PROTECT. DEVICE
S FEM
SANITARY YN
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ IM1ercby effrm thetlhaveecenificute ofronsemmsel Ginsurt. orecertificate of
Workers Compensation Insurance or a certified copy thereof (Sm. 380), Lab C.) which
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
rs all empim,m's under this perria.
Pol'uy #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM,0VER 4 (EA)
PLANCHECK FEE
❑ Cenifted copy is hereby fumished.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT. �Q
ENERGY FRE
(This sectio .caul not becompleted ifthe permit is foronehundrcddollus($10))
orless.)
WATER HEATL•R W/VII /ELECIR
I certify that in the perfnnsienceofthe work fm which Ns permit is pernal, l shall
not employ any Person in any matuwr w as to become subject to the Workers
PAID
Compenm,ion Lawsof Califomie. Date
WATER SYSTEM/IRFATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. IT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shell be deeaned revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm thauhere is a construction lending agency for the pelfamumm of
the work far which Ns pari, is issued (Sec. 3097, Civ. C.)
TOTAL: 'D ff Q
ELECTRIC FEE
Lender's Name^'
�'
QTY. „-;!`�,�; �fv1CCIIANICAL PERMIT FEC
"' `
PLUMBING FEE
Lenders Address
I certify that I have tend this application and state thanthe shove information is
correct. l agree to comply with all city and county ordinances and state laws rehting to
"' -'
PERMIT ISSUANCE
MECHANICAL. FEE
bmidingcons action, and hereby authadm repreaenutives of this citymenmr upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save. indemnify end keep harmless Ne City of Cupertino against
liahi" gmrn`a rem=it expenses which may in any way amme against said City
AIR HANDLING UNIT (TO 10,000 CFM)
d
o rnce the grenung of Jy peri J /
C�A/IO/C/ f�IFV.
i It/`) 64 6
AIR HANDLING UNIT (OVER 10,01X1 CFM)
Signature of Applicam/Contractor Date
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT (TO 100,000 BTU)
,x HAZARDOUS MATERIALS DISCLOSURE
Dote Receipt#
Will the applicant or future building occupant store or handle hinardous material
u defined by the Cupertino Municipal Code, Chapter 9.12, and the Health cod Safety
HEATING UNIT (OVER i00.000 BTU)
TOTAL:.) G���
VENTILATION FAN (SINGLB RESID)
Code, Section 25532(e)7
13 Y. ❑ No
ISSUANCE DATE
WillthenPPlicnntnrfuwre buildng cu am uu a c ntnrdeviaswhich emi
BOILER - COMP 3HPOR I00,000 BTU)
BOILER - COMP(OVF.R 100,000 BTU)
Institutions air contaminants as defined by the Bey AreAir Quality Manegcmcnt
DistriDistrict?7
PAID ykN � D s11
NEW RESIDENTIAL MECII. SQ. IT.
❑Yee ❑ No
1 have read the haurdous materials requirements under Chapter 6.95 of the
07
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
JUN 1993
if the building does not currently buve a tenant, that it is my responsibility to notify the
occupant of die requirements which most be and pnor to issuance of a Ctnificme of
Occupwcy.
Ons .err V VrCM I IMV
ISSUED BY:
Owner, or mahndaed agent !Date
TOTAL:
11 OFFICE