25700 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO H ILDI -ELEU RI A. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25700
RUIBUING PROJECT'IDEN'I IFTCATION,
BUILDING ADDRESS: tK, �F SANITARY NO. APPLICATION SUBMITTAL DATE
UIV�J UNIT# LOTH \�`
O ? S NAME: PHOM'R
NE: D CONTMCTOR'S NAME: R
_
NIC COOLA IIIVCI II QCT GINGER: LIC NO: DR..S: ❑
AIAI lJ L E �o
CONTACT: PHONE: BUIEDING PERMIT INFO
QT ELECFRICP13RMIT 'FEE
BLDG ELECT PLUMB `M.EiCH
PERMIT ISSUANCE xl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION W
y�y Ihereby affimtthat l um licensed underpmvisionsofC apter9(commencingwiN
00 Sectioo7M1b.fDivisioo3ofdm Nusinessand Professions Cale,end my license is in PANELS
yd full for andeffxt. A..- c �P
FyVy,, e s I.ic.# IIP T02(XIAMPS /'` v��y
Frn�• Cminneta, 201.light AMPS ` L
z8ni5 ARCHITECTS DECLARATION OVER UXO AMPS SQ.PI'.FLOOR AREA $ISQ.PI'.
Oz'-p I ndemtand myplans thing be used as public records.
rN
_ tie SIGNS ELECTRICAL
Liccrued Professional
"•y�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
kO y V I hereby aff that I am exempt from the Comtracnra License Law for the
W 3 t F following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,idler,improve,demolish,or repair any structure Y� prior to its issuance,also requires the applicant for such permit to rile a signed statement POWER DEVICES
MAC that he is licensed plan uaneto the provisions of tha Crammer.License law(Chapter
n, a�' 9(commencing with Section 70M)DI'Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y' �y or that he is exempt h=rmm and the basis for the alleged exemption.Any violation of OUTLE'f5-SWITCHES-FIXTURP.5
s.. Y Sectio 7031.5 by any applicant for a Permit subjects the applicant to u civil penalty of
not more Into five hundred dollars($5011).
❑ I,esnwncro(thepropcny,ormycmployeeswithwegesasthdrsolecompensetion, NEW RLSIDLNTIAL ELP.CIR _SQ.FT. STORIES TYPECONSTRUCTIO
a will do the work,end the swctureis not imendedoroffered forsaie(See.7044.Business
and Professions Cede:The Contractors License Law does not apply to an owner of
propcnywhobuildsmim shoo:x Ihereav,and whodaeesuch work himselfarthmugh Ns
employees,pmvided that...hinsprovermanswuremit intended moffercd foreaIs.If, OCC.GROUP RES.UMTS
however,the buildingor impmvemem is sold withinou yearofcompletion,theowner-
budderwillhavetheburdenof that he did not build or improve for f TOTAL:
proving p parpoaea
sa❑le.) ,t!v FLIJMBING P
P.RM17p PEE 1)1)03I,as ownerofthegropenyam exclusively with licensed contractors t QTY
- ennsuuct the mutter(See 7044,Business and Professions Code;)'Dm Coomma.
Licensalawdounm apply to an ownerofpropeny whobuildsor improvestherma,and PERMITISSUANCE
whormarsctafor such pmjeciswith a commitments)licensed pursuant to the Contmcmra
Lacrosse ALTER PA
J FEE SUMMARY
❑ I um exempt under Sa. ,B&P C for this mown BACK MOW PROTECT.DEVICEOIXISIDE It=
SANITARY Y N
Owner Date l RECEIPT#
AT
WORKMAN COMPENSION DECLARATION DRAINS-FLUOR,ROOF REA. SCHOOL TAX Y N
❑ Ihcraby effism lharlhaveaccnificurc O(consent to edFinmrc,oracenifio#te:ofII V RECEIPT#
Workers'Compensation Insurance ms certified copy thereof(Soe.38011,Lab C.)which fUI - ER PARK FEE Y N
covers all employee's under This pemsit, t RECEIPT#
Policy# GAS EAagYSTR I I C. OU .
�+ ✓ BUILDING DIVISION FEES
Company d. fy1S�P&$YSTEM-0 PIANCI IECK ME
❑ Cenifted copy is filed hereby w th the city
❑ Ccnified copy is filed with the city inspection division. SIONDU R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASUTRAP SOIIS ME
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is fmone hundmddollan(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or bras.)
I really that in the performame of the work for which this permit is issued,l ahai[ WATER HEATER WNENT/ELECTR
not employ any person in any morn,,ao as to bacon.subject to the Workers PAID
Compensationlaw,ef California. Date WA1'ER SYSTEMOREATING Data Reecipl#
O NOTICE TO APPLICANT:If,afmmnaking this Certifmate of Hxemption.you should N13W RESIDENTIAL PLM]L SQ.Fr. 'TOTAL:
1)J become subject to the Worker's Compensation provisions of the Lady Cade,you must
7 forthwith comply wish such provisions or this permit shall be deemed rev.ked. BUILDING FEE
Q CONSTRUCTION LRNOING AGENCY SEISMIC FEE
Vz I hereby affum thatthem is a construction lending agency for the performance of
O the work fm which this permit is issued(Sec.30?7.Civ.C.) TOTAL: ELECTRIC FEE
Lander's Name
u" ,Y. .MEC
Lenders Address QT, HANICAL PERMIT , FEE' PLUMBING FEE
u
W I certify that I have read this application and state that the above information is `7
correct.Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE M17CEIANICAL FEE
Qr buildiagmummetion,and herebynmhnrizerepresentatives ofthiscity mele'disnthe
y CONSTRUCTION TAX
above-metnigre,properly for unify and purposes.bear ALTI?R OR ADD TO MECH.
V z (We)agree To save,indemnify and keep harmless the City of Cupertino ugeirm
li.biliti Jud ttLeents and exPP��s�which may in any wayecerue agaimuaid City AIRHANDLINGIJNITff0HL000CFM)
int eq.,a. thegmntingofl 's N AIR HANDLING MIT(OVER 10,000 CFM)
ai rt 9 Iicsncacen, actor - Date EXHAUST IIOOB(W/OULT)
/ PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,0M BTU) Data Receipt#
Will the applicant or future building occepant store or bundle hamrdous material HEATING UNIT(OVER IIXI,IKKI BTU) TOTAL:
as defined by the Capetian Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)?
ElYes 1:1 No VENTILATION FAN(SWOLE MID) �1
❑
BOILER-COMP(3HP OR IDLOM BTU) ISSUANCE DATE
Wilhhe applicant mfumrt buildingoccuPantuseequiptnem ordeviceswhichenit
Im,imPstri?ict? DlamPAII)
air coinanta u defined by the Bey Atee Air Quality Mwxg,ment BOILER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. N0V a 1993
I have read the harmdous materials requirements under Chapter 6.95 of the
Culifomia I leaith&Safety Cade,Sectiotre 25505,25533 and 25534, I tial,mmnd that /s b
fthe buildingdoes not currently have a arnan6 that his myrespansihility to notify the
Ooccupant of the requirements which must he met prior to issuance of a Campeau,of LU�'rkll/W l�
ccupancy. L►/ ' 1
Owner or euthorimd,gem Date ` i,
Y:
OFFICE