25851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DING
-BC PERMR NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 25851
RUI �)ING PR :LT IDNNTIFICATI(IN
BUILDING ADDRESS: —Rn `` N1VI/T SANITARY NO. APPLICATIONSUBMIITALDATE
Y D Z \ k F>UITN , LOT#
OWNERS ME: PHONE: a,t 7APPLI'ANCES
R' F.! LIC NO: O
` N/C CONTROLM
ARCI ECT/ENGINEPR; LIC NO: �/ ❑
xv
CONTACT: PHONE: "" BUILDING PERMIT INFO
E4EQRIC PERMIT FE8
ELECT PLUMB MECH
r, ITISSUANCE ^�LICENSED CONTRACTOR'S DECLARATION -RESIDENTIAL JOB DESCRIPTION
Qwz I hereby affirm that T am licensed underprovisionsof Chapter9(commrncing with�OO Section 7000)ofDivisionJ ofshe Business andProfessionsCade,and my license is inS
F<M License Close t Conti
/ U 1-1000 AMPS
�{
mQz Dem Contra for Y/ VVV`
t—y Z_ II ECTSOECL TIM ,N^ 2B1 II"AmS SQ.FT.FLOOR AREA E/SQ.FT.
20 y I understand my plans shall h used s public records. a�C/ OVER 1000 AMPS
OZ—W SIGNS ELECTRICAL
N_
Q .,] Licensed Professional
XOd'6 OWNER exempt Rm the CoATION SPECIAL CIRCUIT/MISC.
a O0.0 I hereby affirm that 1 am exempt Truce she Conuscmla License law for the
W 3 C,wa following reason.(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR POLE MST.
k 41 Oy J which requires a permit to construct,alter,improve,demolish,or repair soy structure
y�,7 prior to its issuance,also inquires the epflicarafor such Permit to file a signed statement POWER DEVICES
C that he is licensed pursuant o the Provisions office Comem's License law(Chapter SWIMMING WG POOL ELECTRIC
X� 9(commencing with Section Y000)of Division 3 ofthe Business and Profusions Code) VALUAIWOik
W_, or thin he is eumpt therefrom and the hear far theulleged exemption.Any vaAmion of OUTLETS-SWITCHES-FI%TIJRES A � C•�
F-Z< an
Section 7031.5 by y applicant for.permit subjects the applicant We civil penalty of
5 T 0 not mom Then five hundred doll..($500). NEW RESIDENTIAL ELECIR g .PT.m C1I,.ownerof0eMpwy,ormyemployecawithwsgmwiheirwlecompensauon, Q STORIES TYPECONSTRUC`HON
p, will dothework.and the struaurcisnq atendedoroffertdforwle(Sac.]04,L Business
.it Professions Cade:The Comralwe,License Luw does not apply to an owner of
property wh.build,mimpmvess erwn,and who loos such workhimaelforthroaghhie
0wnemployces,provided that such improventenumd
are notimended.roffefor Wc.If, OCC.GROUP RFS.UNITS
however,the building.,impavemem is sold withinone yearofwmpleacat,theowneo TO �-
builder will have the burden of,owing that he did not build or improve for perp rs of
sale.).
❑ I,asownerofthepmparty..mexclusivelycomrwtingwlNlice.udcmweWsto QTY'.'. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.2(Hq Business and Professions Code:)The Contractor's
License Law does nm apply,.anownerofpmperry who builds or improver theeoo,and PERMITISSUANCE
who contracts for such projects with u c.nwctogs)licensed Fursuwt to the Convectors ALTER-DRAIN&VEM WATER EA
License law. ( > FEE SUMMARY
❑ I em exempt under Sec. .D&P C for this reuwn BACK PLOW PROTECT.D TCB OUTS[DETE-9
SANITARY YN
Owner Dam RECEI
DRAINS-FLOOR,ROOF,A ND
WORKMAN COMPENSATION nttomRATION SCHOOL TAX Y N
❑ wh Compensation
rectified
conunnoof(Secure,0r Lab C.)which FIXTURES-PER THAT RB IPfN
Wmkerx COmpensntion lnsumncearecenified copy thereof(Sec. Lab CJ which PARK FEE Y N_
cnvcm all employees untie r GAS-EA.SYSTEM-1 INC.40UTLET RF
Policy BUILDING VISIONISION
FEES
Company GAS-EA.SYSTEM-OVER 4(CA) PLANCHECK FEE
❑ nified copy iaharcby famished.
ificd copy is filed with the city inspection division. GREASE/1NDUSTRL WASTEINTERCEPPOR GRADING TEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectionneed not be completed ifthe Permit is froone hundrWdollare(5100) SEWER-SFTRf%AE .2 F HRGYFEE
.r less.)
I certify that in the perfomtwu of the work for which this permit isi.ued.l sM1ellWATERH `IRI ry:
our employ any person in any manner w as to became subject 1.the Worked PID
Cmr,war ati.n Lawe of C.lif n ia. Date WATER S Du Receipt N
O 7-. Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should HE TOTAL:
E-' n became subject o the Worker'.Compensation provisions of the Labor Code,you must _ _
forthwith comply with such provisions or this permit shall be deemed revoked. :CONS�UMOMVAX
EC4 1
W 5 CONSTRUCTION LENDING AGENCY
1 hereby that the.is a commuction lending agency for the performance of
U So
O
the work For which this permit is issued(Sec.709'/,Civ.CJ TOTAL: ELECTRIC45
�-
U. Lavdm'a Name
Lenders Address QMTYi MECHANICAL PERMIT FEE
U 1 ccnify Nat 1 have road this application and sure that the.bove m otmoti.n is AL :E
>1 W coned I agree to comply with all city and county ordinances and state Iowa saluting to PERMIT ISSUANCE
tbuilding construction,and hereby authonss.pearentativea ofthis city teener upon the
U Z .hove-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep reorders the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO MIKE CFM)
in convaww cc of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM) L �
Signmuu of Applicam/Commoor Dun E%IIAUSTHOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,100 BTU) Dam Receipt#
Will the applicam or future building occupmt store or braille hanWous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? eel T
VENTILATION FAN(SINGLE RE$ID)
El Yes No ISSUA E TE
Will theupplicam urfmurebuildingoocupentme equipment ordevices whichemit BOILER-COMP(JHP OR 100.000 BTU)
hnaarduus nir comaminwits as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
�..Dlsrrlct? �( V pp
❑Yea _ I/1 No
NEW RESIDENTIAL MECH. SQ.IT.
A V
1 have read the hamvlwas materials requirement.under Chapter 6.95 of the V Q
California Health&Saba Code,Sections2l 533 and 25534.1 understand that �1'Sn 2 1994
if the building does cu ensly haves atyA at it is my responsibility to notify the
acuprom of the r uiren tts ich ufGe mm p' r m issuance of a C nificnt of
Oceapwey. CIfy
Owner or
moth zed ant +I Dna TOTAL: ISSUED BY:
OFFIC
ADDITIONAL, PERMIT FEES
�1
BUILDING PROJECT I DENI}IFICATIOFJ VALUATION
BUILDINGADDREM
p
ORNER'5
NAMES FEE SUMMARY
CONTRACTORS ( BUILDINGNNII
y' (}C1f-1� •'s�CL. K Ic.No. PLAN CHECK
CONTRACTOR FEE �•�
Eu
� 7 P o s c .-ERI&V '/7/ SEISMIC FEE 1 C �
OTY. ELECTRIC PERMIT FEE _
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL '
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Z
F 4 TOTAL
Ir T ISSUANCE DATE
LU > OTY. PLUMBING PERMIT FEE SDG. ELECT. RLG. NIECN_
CL Q
::) Z ALTER-DRAIN&VENT-WATER IEA.) /
u O BACK FLOW PROTECT.DEVICE
LL U DRAINS-FLOOR,ROOF,AREA.COND.
Ca FIXTURES;PER TRAP
n ` \ '
F z GAS-EA.SYSTEM-1INC.4OUTLETS
C.7 GAS STEM-O41EA.1
INDUSTRIASTRIA L WASTE INTER.
LAWN SPRINKLERS-I INC5 V.B.
LAWN SPRINKLERS-OVER 5 IEA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM k I
WATER TREATING EQUIP. P� D
Y P�
TOTAL A.
QTY. MECHANICAL PERMIT FEE 12 1994 T
ALTER OR ADD TO MECH. ruut C
NCE /TI/lyV .
AIR HANDLING UNIT ITO IO=E5A_
AIR HANDLING UNIT(OVER 1O=C.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)"
BOILER-CC"13 H.P.or 100,000 B.T.U.) '
BOILER-COMP low•IODOOO BTUI SEE FEE SCU. -
TOTAL