25929APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO I"- -. -
BUILDING [)[VISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMH NO.
25929 C GJ
BUILDING ADDRESS:
SANITARY NO.
ICAONSUBMITI'ALDATL
APFLH
6 g:
h f 6,(- UNIT N LOT#
{
O RSNAMI'f PEON
PGt Gc
CONTRACTOR'SNAME: LIC NO:
NIC
❑
CONTROLp
RCHI'MCM LICNO:
ADDRESS:
CONTACT: irPHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECII
El 11 11 El 11I
PERMIT ISSUANCE
( �
LICENSED CONTRACTOR'S DECLARATION
I herebyalTnn that l am licensed under provisionstdCTapter9 (comme rm, with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section7")af Division 31d he Businessland Professions Code, and my license is in
full familiar] affe5y ,�h�
License a Lim. p _�
Date W V44 Contractor
PANELS
U 0 AMPS
�(
HXJ
2011 - IOW AMPS
ARCHITECTS DECLARATION
� I undemmnd an, plans shall be used as public records.
1
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/$Q. FT
SIGNS ELECTRICAL
jLicensed Prefessiond
SPECIAL CIRCUIT/MISC.
r
• OWNER -BUILDER DECLARATION
1 hereby affirm Ill., 1 am exempt from the Contractors License Law for the
a following mason. (Section 7031.5. Business and Professions Code: Any city or county
® B ra . I
TEMP. METER OR POLE INST. �.
�� /�
jwhich requires a permit to commuct, alter, improve, demolish, or repair any saucmre
c prior m its issuance, also requires the applicant for such Permit to file a signed statement
�j�tl'
99
_
POWER DEVICES
j that he is licensed pursuanuo the provisions of the Convectors License Law (Chapter
= 9(commencing with Section 7000) of Division 3 of Ne Business and Professions Code)
or that he is exempt therefrom and the basis for' Ne alleged exemption. Any violation of
• Section7031.5 by any applicant for. permit subjects the applicant to a civil Penalty of
SWIMMING POOL ELECTRIC V
V
/.�
7
LUATION
OUTLET'S -SWITCHES -Fl URES
not more Nun five hundred dollars ($500).
❑ I,asownerofthc propmy,ormycmployees withwagesas Neirsolemmpemadon,
NEW RESIDENTIAL ELECT SQ.FT.
STORE
TYPECONSTRUCHON
wiRdo the work, and the stracmreisnot intended proffered forsale(See 7004. Business
and Professions Code The Contractors License Low does not apply to an owner of
property who builds or improves thereon, and who does such work himself er through his
tun employees,Pmvided that such improvements me not intendedoroffeted Tarsale. If,
OCC. GROUP
RES. UNITS
however, the building or improvement is wild withinon, ycarofcomplefice. Ne owner-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL: 3 a�
Q TY, PLUMBING PERMIT FEE
.ale.).
❑ Las owrmrofthe aclarsm
exdusivelycmnfessiosCde:)
FLOODLONE APN
Sec. 70,am
he Ca
License the project (Sec. ]Oa•s, Business and Professions Cale) The Carman,
LicenseLow does not applym a who and
ors
PERMIT ISSUANCE
arm acrofpmperty
who Licem,Lacts w,B,r,wch prpjccrswithaconvuctor(s)IimmWpursuanuo Ne Contractors
ed premmproves Contra
License Law,
ALTER EA
( )
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
Owner Data
DRAINS - FLOORROOFAREA, COND.
, ..
SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm thou huvcacmificme of conxm mxlf-insure, oracenificate of
Workers' Compensation Insurance ora eenf(Sec" ifiedeopy therro3800. Lab C.) which
coven all employee's under this pem dt
Policy #
SCHOOL TAX YN
RECEIPTp
FIXTURES - PER TRAP
PARK FEE YN
RECEIPT #
GAS - EA. SYSTEM- INC. 4 OUTLETS
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4(EA)
PLANCI IECK FEE
ay
El Cambers!
❑ niiecopy is hereby famished.
CI Ceartifiedst copy is fled with the city inspection division.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEF,
This section need not be completed ifthe permit is forane hundred dollars ($100)
orlcsa
SEWER - SANITARY -STORM EA. 201T.
ENLRGY FEL
I certify that in the performurttof Ne work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Wmkm'
Comnmerairse aeso(Califomia. Date
Applicant
WATER HEATER W/VENT/ELECTR
PAID
Data Rec If
WATER SYSTP.MOREATING
NOTICE TO APPLICANT: If. a@r making this CeniBcam of Exemption, you should
subject m the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. ET.
TOTAL:hecome
forthwith comply with such Previsions or thispermit.d all bo deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
1 hereby from that hem is a construction lending agency for the performance of
SEISMIC FEE
TOTAL:
ELECTRIC FEE ? t v
J
the walk (or which this perem, is issued (Sa. 3097, Civ. C.)
lander', Net
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify Net 1 have read this application end sure that the above infra m ich is
PERMIT ISSUANCE
MECHANICAL FEF,
correct. l agree to comply with all city and county ordinances and state laws mHung to
building cansvuction, end hereby uuthoriae repeclartativesof abomity to rnrar upon the
above "immaterial property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City Cupertino against
liabilities,judgmnuto
c, cosanichdcxpcnseswhneny � ccmeagai Imid y
in amsequeaccof Ne gram ing of Nis
ALTER OR ADD TO SUCH.
AIR HANDLING UNIT(TO IQOOOCFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER 10,000 CFM)
m of Appli t/Conmelor D e
EXHAUST HOOD(W/DUCT)
PAID
I fEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slam or handle EWmdous material
to defined by the Cupertino Municipal Coke, Chapter 9.12, and the Health and Safety
Ede, Section 25532(q]
Uam Raeiptp
> ?
T0TAL: 33r
VENTILATION FAN (SINGLE RESID)
11 year 0 N
Will heapplicamorfULumbuildingaccupamuxequipmentnrdeviccswhichemit
BOILER-C0MP(3HP0R 100.000BTU)
ISSUANCE DATE
harardous air conmminanrs as defined by the Bay Area Air Quality Management
Disviny
❑Yes ❑No
P A 9 D
BOILER -COMP (OVER IW.f10U BTU)
NEW RESIDENTIAL MECH. SQ. FT.
Phil mad Inc hamrdone morons(, 5505,2mems under Chapter erni of the
Safcuyently avec aaem.fl25533 andsponsi (understand thm
Cdi6mil Ing does
if the building doee not man. currently have a tenant Nat it is my responsibility m notify the
cupam of the syuiremenu which man be met prior In issuance of a Cenificem of
��g 18 1994
D"ap'a'c"
C1IY Ur kvrrrAluvu
BY: (j ( y
Owner orauthonu rtpam Dore
TOTAL: ISSUED