25354APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
IH A
CITY OF CUPERTINO B - .. .
BUILDING DIVISION APPLICATION/PERMIT PLUMBI.NG - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
2 5 3 5 4
BUILDING ADDRESS: , 1
L�1 UNITM LOT#
SANITARY NO. APPLICATION SUBMITTALDAT'E
_ 3
O ERSNAME: PUO
CONTRAgMR NAME: LICNO:
tszkme.
N/C
❑
CONTROLp
RCH13'ECTJEIGINE : LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG ELECT PL�U�M�B` MECH
1:1 E]I.LY ❑
PERMIT ISSUANCE
LICENSE CONTRACTOR'S DECLARATION
I herebyaffirm Ihat I amlicensed under provisions ofCTapta9 mrsomenciagwith
Section 70th) of Division 3 of the Business and Profession licenseCode, and my license is In
full force and effect.
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
Ih)
License Class I.it.#
UPT02MAMPS
e— r
201 - 1000 AMPS
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used ns public records.
OVER 1000 AMPS
SQ. Fr.7FeY0ORAREA
$/SQ. FT.
SIGNS ELECTRICAL Ilasta
Licensed Professional
OWNER -BUILDER DEC
Isaa
SPECIALCIRCUIT/MISC.
' ��
CiamenON
1 hereby mason. Se Wan I am exempt from the GosionsC9 Littnu Lew for the
S, Business Code: Any city strode y
followhich inssumsa
L e '
l'EMP. METER OR I'OLF. INST.
conot improve,
which requires a permit m cmnsweL eheq improve, demolish, or repair any atrucwm
permit ve, demolish,
priorsinsiuumce,alsoret permits etammcnt
hrapplicantl'the
POWER DEVICES
P it �,
to the ContractorsLicense Law (Chapter
LicenseLa
9(c he is Incl ng w p Sectio m the pro Dreisi of the mBusiness
9(commrncing with Section 7000)of Division3of the Business and professions Code)
SWIMMING POOL ELECTRIC
ION
Or he is exempt therefrom and the hands for the alleged exemption. Any violation of
703 LS by any applicant for a permit subjects the applicant o a civil penalty of
OUTLETS-SWITCHFS-
FIXTURES
five hundred dollen ($500).
of dole,
withwegaasdsSene.compensation,
Lasawnav,urk,rend
NEWRESIDEJTIALELECTR_SQ. FT.
STORIES
TYPECONSTRUCTION
do the and the ss
the met..
inu ouintendedse
an he Cont
Lae does not
and Professions Code: The Continuous License Law does not apply to an owner of
sions apply to an owner of
property whobuildsorimprovesthereogand who does such workhimselfornhrough his
es,providednlism improv If,
ene earolfdmoffemdfoeowmr-
own ear,
OCG GROUP
RES. UNITS
TOTAL:
the within
buildrstile.
prove
howevr,theirmlIvgarimprovement issold withinonemidmcomplmioo,the owner-
builder will hav<the buNen of proving thn he &d von build or improve for puryose of
QTY. PLUMBING PERMIT FEE
safe.).
❑ I,mowner ofthe pmperty,emexdmivelyconundmg with licensed contradorvm
FLOODZONE
APN
construct the project (Sec. 7014, Hosannas and Profusions Code:) The Cantmcmr'e
License Law does not apply to an owner ofpromr, who builds a improves thereon, and
PERMIT ISSUANCE
who comets for such projects with a contractors) licensed pursuant to the Commetore
License Law.
ALTER -DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
oCTRD—F—FM
SANITARY Y N
RECEIPT
Owner Dan
DRAINS - FLOOR, ROOF. AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTA% Y N_
❑ Thereby uffimn that l have a certificate ofermaxnn to ulf-insure. or a cenifieme of
Workers Compensation Insurance or a certified copy thereof (Sas. 3800. Lab C.) which
covervall employee's under this permit.
Policy #
RECEIPT #
FIXTURES - PER TRAP
PARK TEE Y N
RECEIPTp
GAS -EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM OVER 4 GGA)
PLANCHECK FEE
❑ Cerifedcopy iahercbyfumished.
GREASEINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS ME
COMPENSATION INSURANCE
SEWER - SANITARY - STORM G. 200PT.
ENERGY FEE
(This section need non be completed ifthe Permit is Income hundred dollars(S IW)
or less.)
WATER HEATER WNEWIELECfR '
I certify that in the performance of the work for which this permit is ismad, I shall
not employ any person in any manner so as to become subject to the Workers'
Cempensatiomiswsuf Califomie. Dote
PAID
Dam Receipt It
WATER SYSTEM/TREATING 3s J O
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to Ne Worker's Compensation provisions of the Labor Cale, you must
forthwith comply with such Provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
TOTAL: � db
ELECTRIC FEE
lenders Name
QTY; . MECHANICAL PERMIT FEE
PLUMBING FEEn
�QO
Leaders Addm
I certify that I have mat this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating he
PERMIT ISSUANCE
MECHANICAL FEE
buildingeommuction, and hereby authorize represenmtivesof t dschy to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify eM keep hemd<ss the City of Cupertino against
liabilme,judgmcntscosn avde,seses whichmaym my way accuse sguman said City
AIR HANDLING UNIT TO 10,000 CFM)
in cZwop``eca ofthe gr ting of is permit
y/ S/1�
AIR HANDLING UN(OVER 10,n100 CFM)
E%HAUST HOOD(WIDUCD
PAID
�n 7,/ZS
Signature of Applicamn7ontracna r "T
HEATING UNIT(TO 100.00 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildnt ing occupastore or harshe hazardous material
us defined by the Cupertino Municipal Code, Chapter 9.12, and WHealth and Safety
Date Receipt If
HEATING UNIT (e OVER 100,0011 BTU)
CIO
TOTAL: 1 ��VO
VENTILATION PAN SINGLESINGLERESIO)
Cale, Section 25532(a)7
❑ Yes ❑ No
BOILER- COMP(3HP OR IN." BTU)
PSkIftVATE
A� {V/
Will the applicant or form building occupant use equipment or devices which emirs
BOILER - COMP (OVER 100,000 BTU)AA'+�
hazardous We commitments as defmul by the Bay Area Air Quality Management
District)
❑ Yes ❑ No
JUL 231993
NEW RESIDENTIAL MECH.—SQ. FT.
I have mad the hazmdous materials comm menu under Chapter 6.95 of the
California Hcahh&Safety Code, Sections 25505,25533 and 2554. Iunderstamd Net
GII'T Vr UUHtnwrwI
if the building does not currently have a tenant, than in is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Cer ificam of
Occupancy.
�A'^'
ISSUED BY: �cz ✓i
Ownerorauthorieedagent Data
TOTAL:
OFFICE