25645 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1310^T'-FLE,MHTXI PERMITNO.
APPLICATION/PERMIT PLUMBING-MF,CILSNICAL
INILDIN(i DIVISION BUILDING PROJECT[UY.NI'1FICA'I']ON 25645
BUILD NO
i ADDRESS: SANITARY NO. APDLcAnob/,.suBlonTTAAL DATE
7-1.rLo 1, LX_L—_J• J 0
UNIT# LOT I
Wy�f
I55NAME PHONE: NTRACTOR'S NAME: LIC NO'. NIC CONTROL#
isTZAZ_+91X- 6 fxs5�✓L C /--k iC_b4Wrcl_ � 53045 0
RCIIITECI'/f:NGINEER: LIC NO: RLSSO. 1 IJCTLI2s..t� ��_
'ONTACT: PHONE: QTY.. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0, A El
LICENSED CONTRACTOR'S DECLARATION APPLANCES-RESIDENTIAL
LOB DESCRIPTION
pyz Iherebynffrm that l am licensed under provisions ofatipter9(commencing with
001— ction](KKpof Division dnf le M1Business and Pmfcssimns Code,and my license is in PANELS
11 force and ef
�Vk3
isenc Claes�L_ UP T0200 AMPS
Fd<c. Lic.p
memDateComracmr 201-1000 AMPS
i- SQ.IT.FLOOR AREA S/SQ.Ff.
,,Z ARCHITECTS DECLARATION OVER 1000 AMPS
Z O m 4)
OZ-4) 1 understand my pleas shall teased as public records.
rn F; SIGNS ELECTRICAL
Licensed Professional
�CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC. I
KOa V 1 hereby if,.that I toe exempt from the Contractor's License Lew far the 11
W'3ay following mason.(Section]O11.5,Business artd Rofessions Code:Any city ar county TEMP.METER OR POLE INST. 'I
F 05 which requires a permit m conshu<t,nbeq improve,demolish,or repair any strvcam ,.
$N
!jag priorm it,issunnce,also requires Ncnpplicam for such permitm flea signed statement POWER DEVICES I�a that he is licensed purtuant to the provision,of the Contractor's License Law(Chapter
w ELM= SWIMMINGPOOLELECIRI V LUA9'ION
aao� )(commencing with Smion]000)of Division Sof the Business arN Professions Cade)
orlhathe m ausurpt themfmm and thebasisfartheollegelenemption.Any violadmof It
g ZY Section 7031.5 by any applicant for a permit subjects the applicant on civil penalty of OUTLETS-SWITCHES-Fl RES
O more than rive hundred dollars($50f).
nNEW RESIDENTIALELECfR _SQ.Ff. S'1'ORIs. - TYPECONSTRUMION
to m m❑ I.asownerofNepropery.ormyemployaswithwagessstheirsolecompew m,
n3. will do the work,andtM1e structure isnot intendedoreffdeal for sale(Sce.9lW4,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself umhrough his
ownemployccs,pmvidcd NauucM1improvcmena art notimmdedmoffcrtdforsale.IL OCC GROUT' RIiS,UNITS
however.the building or improvement is sold within one yearafcomplcdon.the owner. TOTAL:
builder will hove the buNcn ofproving that he did not build Or improve for purpose of
xv1c.). QTY. PLUMBING PERMIT FEE FLOODZONIl, APN
❑ I,as ownerofthepmpeoy,amexclusively contracting with licensed contractors to
construct the project(See 7044,Business and Professions Cade:)The Conumtma
License Law does not apply to an owaeTefteopeny whobtildsor improves thereon.and PERMIT ISSUANCE
who contracts rurmeh projectswith a rt
cnmmcuad.)licensed puuumt to the Contractor's
License Law. ALTER-DRAIN&V17N'T-WATER(EA) F`EE SUMMARY
❑ I am exempt under Sec. ,B&P C fm this rexwn UTSID E FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner DmaDRAINS-FLOOR.ROOF,AREA.COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that l have acerificre ofconsent tosalf-insure.oramnificateof MIXTURES.PER TRAP RECO?1P1'p
Workers'Compensation lasurancear a certified copy thereof(Sev.3800.Lab C.)which PARK HE Y N
nrvers all employeeun
's der this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECF.IPP p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK HE
❑ Cerifiedcopyisherehyfumished.
❑ Certified copy is filed with the city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is(mons,hundreddollart(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
less.)
I certify that in the pamformance ofihe work for which his permit is issued,I shall WATER HEATER W/VENT/ELECTR
mol employ any person in,any manner w as to become subject toe the Workers' PAID
Compensation laws is Cul' cis. Date -. WATER SYSTEMICREATING Date Receipt#
0 2 Applicant
Z NOTICE TO APPLICANT: after making this Certificate of Exemptiam,you should NEW RESIDENTIAL PI.MB. SO.FI'. TOTAL:
become subject to the War Compensation pmvisioas of the Labor Code.you must
forhwithcomplywithime Provisions or this permit shall be deemed mvaked. BUILDING TEF.
0. 0 CONSTRUCTION LENDING AGENCY SEISMIC PEE
,Z 1 hereby affirm that there is a corutrax ion loading agency for the performance of
U O the work for which this permit is issued(Sce.3097,Civ.CJ W ELECTRIC FEE
r Lender's NamePLUMRING FEE
F' leaden Address QTY. MECHANICAL PERMIT FEE
O U I certify Nat I have read this application end sore that the above information is MECHANICAL PER concct.Iagmctocomplywithallci"v .wu 'yoNnv ccsa slnelawsmlatingto PERMIT ISSUANCE
building construction,and hereby amhodm representatives ofthis city wenterupon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify said keep harmless the CityyPPFCtipcnino against
Iiabiluies.judgmems,costs and o PS m whichmayinan accmeagainst said City AIR HANDLING UNIT(TO 10.000 CFM)
nseyuence of the grvmimg vpermit. AIR HANDLING UNIT(OVER IB,(IOO CFM)
Signature of plicentlContmcmr Data EXHAUST HOOD(W/DUCT) PAID
I IAZARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO 100,000 BTU) Date Recci
Will the applicant of future building occupant start or handle huuWous material HEATING UNIT(OVER 1 W.OW BTU)
as defined by the Cupertino Municipal Cade.Chapter Y.12,and he Ileelth and Safety
Cade,Section 25532(a)] VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE DATE
WilltheapplicantnrfulurebuildimgmeupaniuscequipmeniordeviceswMchemit BOILER-COMP(3HP OR IW,(ft BTU)
harardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1M.M RTU)
District?
❑Yes ❑Na NEW RESIDENTIAL.MECH. SQ.IT. A rr p9
I have mad the hamakno materials mquiremems under Chapter 6.95 of the tl Y
California health&Safety Code,Sections 25505,25533 uad 25534.I undersand that
if the building Jaen mol curen0y huvicetenan6 that it,,my respomihillty 11,notify the OCT 19 1993
occupmt of Ne requirtmenu'which must be mel prim to issuance of a Cenifi<am of
Occupancy. f�
Owner m auL:lhorived agent Dale TOTAL ISSUF,)fI IYyWt.! I
OFFICE