25638 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I .- A PERMrr NO.
APPLICATION/PERMIT PLUMBING MECHANICAL X 6 3 8
BUILDING DIVISION BUILDING PROJECT'IUEN'ru9CATION Jv o
BUILDING^IADDRESS: '1 [[ SANITARY NO. APPLICATIONS SUBMITTAL DATE
QG s�"� �G UNIT# LOTH 1 ass LA
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: Nrc CONTROL#
m e�#lS�.t/ 2- S3
•ARCHITECDENGINHIL LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELE 1 ERMIT PEE
BLDG ELECT PLUMB MECH
PERMITIS N ❑
LICENSED CONTRACTOR'S DECLARATION p - FSIDE
O L'Z I hereby affirm that l am licensed unduprovisionsofaia,Z9lcommencang with TOB DESCRIPTION
POO C Section7")of Divisim3ofthe Businessxnd Professions Code,and mylicense is in A
y W U full force and effect.
FZw full for Cama Lic.# 00AMPS
vs6a Date Conmctm 2 -1000 AMPAI IPV
Z PrOy� ARCHITECTS DECLARATION OVERT SQ.Fr.FLDD AREA I 5/ .
O Z—O I undcntand mY plans shell bo use.)as public rccurds. C)/V�-
Ey�ul SIGN C
>d '�
Licensed Professional
6C
OWNER-BUILDERDECLARATIONthe Cr ATION SPECT IRC T/M1SC.
V 1 hereby affirm That I oro exempt from the Cnmmno o e:Any law for the
W�Oy
fell.ah., to 700 a.5,Bmineu and Professions deaans Co da Any city orcounry TEMP. TFR ORPoLE INST.
I❑ Q which its ismnPermitre surest a clear,improve,demolish,me.slranysnuaurc
Jon-1
Priorm its iuumec,alxorequircs the applicant far such permiuo fileasigned cmemem POWER DEVICES
tyC�p that he is licensed puuuanno the provisiosss of the Contractors License Los,(Craftu SWIMMING PoOL ELECf1lIC VALUATION,
aXo� 9(commencing with Section7000)of Division 3 of the Business and Professions Code) �O
,^y or that he is exempt therefrom nndthe basis far thealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Z,QSection 703 t.5 by snyapplicantfor.pemti,subjects the.pplicanuo a civil penalty of
r more than five hundred delta.(5500). Q STOIES TYPE CONSTRUCTION
H ' NEW RESIDENTIAL ELECIA S .
m ,asewnero0heproperry,ormyemploymswith wegesuthcirsole c0mpemastess
p, ill Pmfa,i..a ands: nmcmreisnot inlendese La a due, .,.11,.to .Business
lass Professions Cade:The Contredm'e Liana law don nor apply to an owner of
Property wh.b.ildscrunproves thereem,and had.such weak himselfinuoughhas OCC.GRO P RES.UNITS
nempleyees,provided thatsuch improvemen[sate notimendedoroffetedforsole.If,
however,thebuilding or improvement is sold within one yearofcomple,ion,the owner- O I
builder will have the burden approving that he did not build or improve for purpose of
vale.). PLUMBING PERMIT FEE
❑ I,ssownuof the pmpcny,em exclusively contractingmmnQTY.
contracting with licensed cocto
to FI.00DZONE APN
construct the project(Sec.7814,Business and Professions Code:)The Commerce's PERMIT ISSUANCE
License Law darts not apply to an oweerse propany whobus dsorimproverthereon,and
whtemsmacn fmsuch projects with.connected.)Iicaused p.m..mmu Connxetors pI TER-DRAIN&VENT-WATER EA) H UM ARY
License Law.
❑ tam exempt under Sec. .B&P C for this reeaon BACK ROW PROTECT.DEVICE. I' DF.
SAIGAR Y N
Owner Du DRAINS-FLOOR,ROOF.AREA.CO D. RECF.I x
WOR MAN COMP DEC TION L A R # N—
• c❑ Thereby afOrm tMtlhave eccnificetn of consent to self
-insure.macenificateof FIXTURESME_
TRAP p T
Workers Compensation Insurance or a certified copy thereof(See.3800,Lab C.)which P RK FE Y—N
—
Workers
all employee's under this permit. GAS-&1.SYSTEM-I INC.4 OUTLET RECEIPT40
Policy It BUILDING DIVISIO FES
Company GAS-EA.SYSTEM-OVER 4(EA,) PLANCHECK FEE
❑ 'Cenafted copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FTSE
CERTIFICATE OF EXEMITION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This scelannttJ nm be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfoomnce of the work for which this Woods is issued,l shall WATER HEATER W/VENT/ELECTHt
not employ any Person in my msmer so as to become subject to the Workers PAID
Compensation Laws of Cahands. Date WATERSYSTEW17REATING Data Receipt Receipt
Z' Applicant
77� 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Mould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F fA become mbjec,mthe Worker's Compensation provisions f,he labor Code,you as, BUILDING FEE
� ; forthwith comply with such provisions or this Permit shall bm
e deemed resulted.
L>a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this Front is issued(Sec.3097,On.C.)
Lenders Name UMBING FEE
0 Fy Lender's Address QTY. MECHANICAL PERMIT FEE PL
W I certify that 1 have read this application and state that the above information is MECHANICAL FEE
>1 comet.l agree mccmply with all city and county ordinances and cute laws relating to PERMIT ISSUANCE
F' Lo) buildingeousuuction,and hereby northern,repmsenutivesofthisciry,oenter upon the CONSTRUCTION TAX
V Z above-memionM propeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way scour against said City AIR HANDLING UNIT(TO 10,000 CEM)
in consequence of the grunting of this Permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicam/Comenctor Data EXHAUST HOOD(W/DUCIT PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dale Receipt#
Will the applicant m future building de.Cam erre m handle H a Health
a material
an defined by the Cupertino Municipal Cale,Chapter 9.12,and the Heuhh and Safety HEATING UNIT(OVER 100,000 BN) TOTAL:
Cade,Section 25532(x)^ VENTILATION FAN(SINGLE RESID)
❑Yes �51(,No p� ISSUANCE DATE
us(uwrehuildingoccupantuuequipmemmdev
Wall da,plicanices whiehemat BOILER-COMP(311P OR 100,000 BTU) .r A ' D
• hazardous air caraminants a defined by the Bay Ana Air Quality Management BOILER-COMP(OVER 100,000 BTU) I'4
Dialect?
❑Yet >rz- NEW RESIDENTIAL MECH. SQ.1T. DEC - 6 1993
1 have read the bersfdous materials napnermemc under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 undemmd that ,Il Y ur
if building dun not currently haveemnant,that' is my Arsponsibili,y to notify the �VI'th IINLI
pant��of/tltek tcquirem-nn.hath r be mc, /oar m issuance of a Cerr/af/sea/tq of
oca / / •{L11GG1T. �I/yf of
t� agency TOTAL: ISSUEDBY:
OFFICE