25337APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO T1B711NG-F.EEETRICA .
APPLICATION/PERMIT PL'(JMBING-MECHANICAL.
BUILDING DIVISION BUILD ; PROJECTIDEN'I'IF'ICATTON'
PERMITNO.
5�i
J J 37
BUILDDINNOAADDDDRESS:
SANITARY NO.
APPLICA'110NSIJHMD'I'N.DATE
/09S-29—UNI'la LOT#
OWNERS NAME: PHONE:
t PV `V5S
CONTRACTORS NAME: _ LIC NO:
D -C. 0 6
SIC
CO ROLA
A LIITECDENGVN ER: LIC NO:
ADDRESS: -
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB ME II
El 'R1 ❑
PERMIT ISSUANCE -00
LICENS12D CONTRACT'OR'S DECLARATION
I hereby affirm that l am licensed underprovisionsof Chapmr9(cummenciogwlth
I APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7000)of Division 3 afthe Businessand Professions Code, and my license is in
PANPI9
fall form."" el&_c� fi
License Classes Lic.a O
Data %--/ B _-!!_� Comrenm /L
' f gJ ARCIIITECTSDECLARATION I
1 understand my plans shell Na used as public records.
UP TO IW AMPS
3 )1 - 1000 AMPS
SQ. FT. FLOOR AREA $1SQ. FT.
OVER I" AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATIONSPECIAL
CIRCUIT/MISC. OD
I hereby affirm that I um exempt foam the Commemr's License Law for the
following testator. Section 703 1.5, Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
which requires a permit m construct, after, improve, demolish, or rtum any s meture
priormi¢issvamee,alsorc the applicant for such Permit file a signed
quires pP pram BLa
-
n ,r
POWER DEVICESthe
be
000)the of provisionsofthe Contractors and Prelsw(CM1apmr
9(comsncing with Sectiouant n
9(cotmnencingwithSeclion]000)of Division3 of the Business and Professions Code)
or that he is exempttherefrom and the basis for the alleged exemption. Any violatlonb(
Section 7031.5 by ony applicant fm a permit subjects the applicant m e civil punalry of
- -14
qq`( nJ j,� 'p-�`•p •••TTTf���la ATI N
Y 'iJ 1
Y V, P II II p E R
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
nut mortth.n five hundred dollars(5500).
❑ Las owner of the properly, ormy employees with wages as their sole compensadnn,
NEW RESIDENItAL ELECTR _SQ. FT.
STORIES •'
TYPECONSTRUCfION
willdo the work.andibe swcturcianot intended moffcrd faster (Sm 7044, Business
/
1�
and Professions Code: The Commcmr s License Law does not apply m an owner of
property whobuildsorimpruvesthercon, and whodmx.mch work himselforthroughhis
employees, prnviJW Nm aucM1 improvcmenzsamnolimm�dcdoroffend Tressle. If,
however, the building or improvement is sold within one year ofcompletion,sheowner-
builder will have the burden of Nal he did not build or ire for of
proving prove purpose
OCC. GROUP
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
sale.).
exclusively contracting with licensed contrs to
❑ L mowner oldie property, am tacm
FLOODLONE
APN
construct the project (See. 7014. Business end Professions Code:) The Contractor's
License Law docs not apply man owner of property who builds m impravea thereon, and
PERMIT ISSUANCE
whocmnnaye forsuch projects with a contramods) licensed pursuant to the Contractor.,
Lieemsc Law.
ALTER . DRAIN & VEN'T - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. B & P C for this reason
BACK FLOW PROTECT. DEV ICESI
E FEI-
SANITARY YN
RF.CEIPTp
Owner Use
DRAINS-F100RROOFAREA,
, , ..
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y
❑ ]hereby affirm that l have a cenilicae ofconsent to set Blnmre, or a certificam of
Workers'Compensation lnsumnc,maeadi0ed copy thereof(Seo. 3804 Lab CJ which
cavery all employee's under ,hie permit
Policy #
It #
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT p
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTHM-OVER 4 (EA)
PLANCHECK FEE
❑ Certifcd copy is hereby famished.
GREASIVINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cenifcd copy is filed with Necity inspection division.
CERTIFICATE OF EXEMPTION ]ROM WORKERS'
GR17ASE'I'RAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not the, completed ifthe permit is foram hundred dollars ($100)
or less.)
WATER HEATER WIVENTIELECIR
I cenifytha in Ne performance of the work for which this frmit is issued. I shall
not employ ony any, to object m the Workers'
tinn sof Ctn DC1
Cut asm
PAID
Data Receipt#
WATER SYSTEM/TREATING
Applicant '
NOT'1GE TOAPPLICA :If, after making this Certificate of Exemption, yo shoud
NFWRESIDENTIALPLMIL SQ.FT.
TOTAL:
became subject o the Workers Compensation provisions of the Labor Code, you must
ed roked.
comply with such provisions or this permit shall be diamond ev
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is o construction lending agency fm the perfrmrance of
the work for which this permit is issued (Sm. 300], Civ. C.)
TOTAL:
ELECTRIC FEE w b 0
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Name
Lender's Address
1 certify that I have tend this application and slam that the above information is
ces anlaws mlaingto
correct. I agree to comply' with all city mul wady ordimnnum
/
' PERMIT ISSUANCE l �UO
MECHANICAL. FEE 8
building construction, and hereby authorize representatives ofthis city to enter upon the
aMwe-mentioned progeny for inspection purposes.
ALTER OR ADD TO MEC]{. 00
CONSTRUCTION TAX
AIR HANDLING UNIT ('I'D 10,000 CFM)
(We) agree to save, indemnify and keep humblest, the City of Cupertino against
liehilines, judgments. costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (OVER 10.000 CFM)
scgaeaccof the gracro m f this K u.
�(//L�
sncq��f� ��� 7— 1%
E%HAUS'I'f{OOD(W/DUCI)
PAID
Signature of Appl'.mt/Conl c�tor�
BEATING UNIT (TO 1(10,00(1 BTU)
HA]ARDOUS MATERIALS DISCLOSURE
Will flax.,licam or future building occupant smear handle Immortals mucoid
as detinet by the Cupertino Municipal Caxle, CM1nper 9.12, and the Ileahh anti Safety
Date Receipt #
HEATING UNIT (OVER 1010,0010 BTU)
pp
TOTAL: -QV
VENTILATION FAN (SINGLE RISTD)
Code, Section 25532(.)1
❑ Yea ❑ No
ISSUANCE, DATE
Will Oma Iicanlnrfutumbuildin tuu tordeviceswhichemit
po g
BOILER- COMP(3HP OR 100,0010 BTU)
P A I D
BOILER -COMP (OVER 100,000 BTU)
by then Am. Ain
M1uzaMous air naminama as Jefnd by the Ray Arta Air Quality Management
District?
NEW RESIDENTIAL MECH. SQ. PT.
13 Yes 0 N
pI Q
JUL9 1993
the hwnomaterials mr,mmmenis under Chapter 6.95 of the
I have read Nm
California lbefla & Safety Cade. Sections 25505, 35533 and 25534. 1 understand this
it the building does not currently have a tenant. that it is my responsibility to notify the
CIIY vl- vVf [IRI Bry
occupant of the requirements which must be met prim to issuance of a Certificate of
Occupancy.
ISSUHDHY:
Owner or ... horvcd egem Dale
TOTAL: -QV
OFFICE