25134 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILDING-ELLU �
R ' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25134/1
HUIhIkING DIVISION BUILDING PROJN,CPIDF,N1]FICAI']ON LC J 4
B .DINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Ili
II�� �� 1 ['�I� 1a�J ,per- lf�f�—
UNCJ � k{,/ V—`CY l.` UNITio LOT#
p1YL"S ME PHONE: CONT CfOR'S Neto LIC NO:
:RCI IITECT/ENGINEI:It: LIC NO: ADDRF 6A I
CONTA(:1': PHONE: QTY. ELECTRIC PERMIT FEE HUILDING PERMIT INFO
G ELECT' PLUMB MECH
)PERMIT ISSUANCE El
LICENSED CONTRAerproSDECLARATEON APPLIANCES-RESIOEMIAL
zd,L Ihmchy afEmICIdsSEDCOe that I am NTRACTpmvisDECL DECLARATION
JkWiYI{p/-�ra
+)00 fullSecI.and ff Division Sol the Licsi«es�dProfessionS Code^amt my license is in PANELS
UP T0200 AMPS
"W V- full Cana erceat, a,-1/Q�TIS 1/ �`is� '+`
a owe Commnm 201-1000 AMPS
Z A III'IECTSDECLARATION OVER 1000 AMPS SQ.PI'.FLOORA $/SQ.FI'.
I understunJ my pia shall he used as public reamds.
' oZ-O ^ L4
FyF-41 SIGNS ELECTRICAL lJ_
Q 7,, Licensed Professional
ce< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
7a(,00.0 I hereby affirm Thal I—caempl from the Coins ora License Law for the
W't Wr
N followingm om(Seclinn]031.5.Bmi—oitteJ Pmfcaslons Code:Any cityor county I EMP.METER OR POLE INST.
C�OJ which inquires s permit m mnsomet,oda r,improve,demolim.or repair any sWclerc
�n¢7 prior to its issuance.also acquires Ne applicant for such permit to file a signed statement POWER DEVICES
C Nat he is IicensW pursuant to the Provisions of the Contractors License law(Chapter
toe 4 SWIMMING POOL ELECT RIC
d
4.Soe4. 9(commencing with Section]WO)of Division 3 of the Business and Professions Code) f�VALU``AT
Wim nrthm he is exempiihercl tom routine basis for lM1talleged exemption.Any violation of OUTLETS-SWITCHES-FI%TERES I V
FZQ Salton him
iv anyapplicantfornpermit subjects the eppli<wua a civil Pentlty of X106
Z0 smom031.five any amddollars(5500). NEW RESIDENTIAL ELECTR _SQ.FT.
=�ro [I1.asowmrofNepmpeny,ormyemplomswithwngesatheirsolecompensation, STORIES T'YYE CONSIRUCI'ION
ywill do the work,and the structure is not intended oroffemd forsale(Sec.]044,Business
.and Professions Cole:The Contractors License Law does not apply to an owner or
property whobuilds o improves thereon,and whodocssuch work himselforNrough his
own employees.provideldeal such improvementsarenot itnenddorefferd formle.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofeomplclion,the owner. TOTAL:
builder will have the burden of proving that he aid not build or improve for purpose of
sale.).
❑ I,rhsnwnerol'thcpropeny,amenclusivelycontmetingwithlicensdconnaclorslt QTY. PLUMBING PERMIT FEE PIAOD LONE ANN
construct the project(Sec.7044,Business and Piefesslore Cade)The Convector's
Liccnsclawdoe,maipplym anowacrofpropenywbobuildsorimpmvesthercan.end PERMIT ISSUANCE
whocnnnactsforsuch projects with a commemr(s)licensed Persimmon the Contrunor's
License LawALTER-DRAIN&VENT-WATER EA) FEE SUMMARY
.
01 um exempt under Scc. ,B&P C for this mann
BACK FLOW PROTECT'.DEVICE SANITARY
FEES
SANITARY Y N
Owner Dam DRAINS-Fl.00RRUDE, .OND. RECEIPT#
. ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby official that l have acenifcate ofecamen to self-insure cracertificamof IT%TURES-I+HR TRAP RECF.IPP#
Worked Compensator lnsuranceorucenipdenpy Hereof(Sec.JNW,Leb CJ which RKF E YN
anent all employee's under this pemhif GAS-EA.SYSTE - 1 RIiCI;1P1'p
Policy# '" BUILDING DIVISION FEES
Company GAS-FA.SYS'IE -YE� I(6A) I .� NC :CK FEE O
❑ Certified copy is hereby famished.
❑ Cerlilicd copy is tiled witM1 the city inspection Alvision GRIiASFJINUUSTR"WAS��kTE IM'ER(CPTOR GRADIN;FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP D/7T SOILS I.
COMPENSATION INSURANCE
('Ihi.s section need not be completed if Nc Permit is for one hundred dollurs(S100) SEWER-SA ARY-STORMEA.200FT. ENERGY FEE
or lass)
I cedifyded in the perfomtuncc tithe work far which this pamrd is issued,Ishxll WATER HEATER WNFNTpiLECTR
rid Aloy any person to any manner so es to beegnse—)kVI Nc�l crs' PAID
C ipensati rCehT l5 `` WATER SYSTEM/TREATING Dam Receipt#
0 z PPlicam �G� a
7. 0 NOTICE10APPLICANT:IC after making this Cenirica of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
bee da.'object to he Worker's Compereation provisions of the Luton Cde,you mus BUILDING FEB
? ronhwith comply with such provisions or this permit shall be deemed revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this Period is issued(Sec.3097.Civ.Q) TUTAI: ELECTRIC TBE
Landers Name
F Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U0
U I certify that I have mad this application end sate that the those information is
correct. lagree[to comply with all city and county ordinances and state laws minting to PERMIT ISSUANCE �'^ MECHANICAL[:I.
F^ mildingconstrucomi.andherebyanhoriee rcprceemutives of this city nt enter upon the CONSTRUCT ION A1
U z shove-mentioned property for inspection parposes. ALTER OR ADDTO loo lo
Wet agree to save,indemnify and keep harmless Ne City of Cupertino again
liubilitic 'ud,ronts.cosesande hichma yway eccme agtinstmld City AIR HANDLING UNIT(TO 10,000 CFM)
yucnce of the gmgypg This t.
1^/ AIR HANDLING
n �^ e I EXHAUST HOOD
OVIDUVER 1gW0 CPM)
Signature of Applicant/Consador Date EXHAUST HOOD(W/DUCD PAID !
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GO 100,000 BTU) Dam Resecips of
W ill the applicant or future building occupant sora or handle hazardous material ( J
as ddloed by the Cupertino HEATING ON[]Municipal Cao Chapter 9.12,and the health and Safety OVER 11101110,000 BTU)
TOTAh:
Code,Section 2553200? VENTILATION FAN(SINGLE RESID) /
❑Ycs ❑No d1volooll
ISSUANCE DATE
Will heapplic:mlorruturc building occupied use equlpmentordeviceswhichemit BOILER-COMP(3HP OR 100.000 BTU) P f1 p ' D
homraoun air con undrums as defined by the Bay Amo Air Quality Mantgemcnt BOILER-COMP(OVER 103,0110 BTU)
District? MAY 27 1993
❑Yes ❑No NEW RESIDEM'IAL MECII. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California l leallh&Safety Code,Sections 2550.1,25533 and 25534. 1 undersand that CITY ur wrenuw
if tcurrentlyN
e building does not currently have a stand. at it is my responsibility to notify the
,acceptant of me rcquirctrents which must be mel prior to Issuance of a Certificate of
Occupancy.
Owner or autbon ad agent Data ISSUED BY: