25090 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO L I • L MWITND. 25090
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION f� [q'1�--BUILDING PROJECT IDENTIFICATION
HUILDINTRR-ESS: aAWN KOVkJ� Cf-i1 SANITARY NO. APPIJCAT�IOJNSUBMITALDATE
2 6 UNIT# OT# -5—
OWNERS AMC: PHONE: C TRACTOR'S NAME: LIC NO 0
v ni /✓ as2 - 'gas £ o 1 6 NC COM'ROLN
ARCH]'IF.CT(ENGINEER: LIC NO: ADDRESS: I ❑
CONTACT: PHONE:
QTY, Ii4F.CF121C PERMIT p[;E BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE [Yl 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
I herebydfirm that l am licensed underprovisionsof Chepmr9(oommrncingwiN
1000 Section 708(1)of Division 3 of the Business and Professions Cade,and my license is in PANELS C
MF� full fora and etfyt,s Lic.N GWksio1 UPT0200AMPS
az License Class •s/ y ��
Fly Dam Contremnr 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
z0o,,- ARCHITECTS DECLARATION OVER 10(10 AMPS
OZ-8 rn I understand my pleat shall be used us public retards.
_ SIGNS ELECTRICAL
9y�d�'V Licensed Professional
CKOWNER-BUILDER from
DECLARATION SPECIAL CIRCUIT/MISC.
°J Oa 1 hereby affirm that I em exempt from the aontmcto o License law for the
y�3 toaI whichf0loveim,re,hern(Section 70JLABusiness and Professiore Code:Any ad,m a,countyTEMP.METER OR PoLF.INST.
1=2ONJ which rtquircsa permit taconstme,Wmr,ir forsudemch mxh,file
repair myewaure POWER DEVICES
�r�J+0 that hoslicensed IF also requires theapplicatorfor CommmiuoLicese La statement
W qOa Natheis licensedpursuantto the provisionsof the Committees License Lew(Chapter SWIMMING POOL ELECTRIC
0.p,eW 9(commencing wo Seeiase and he Division Softhe Business and Professions Code) VALUATION
Xyl Zoe opdoor tion 703exempt therefrommdthe basPermit subjects
10 civiny l
of OUTLETS-SWITCHES-FI%TURES
'za no,none than by any reddantforapertit wbjecb Ne applicant acivil penalty of
mKm Lonot mi,..a.,rvfthndr ny,ms(ympl NEWRESIDENTIALELECIR 5 .FT.
❑ Luownerand Me spiny,mmyemployedorafwagnasthe(Ses.compcnsiness Q STORIES TYPE CONSTRUCTION
y'$- will duthe ximisande:no umeture
not intendese Law
a.,e(Se,Aim one,
and Professions Cale:The Comrxtnrs License Low docs not apply m an owner of
property who builds orimproves thereon,and whodoes such work Idrmelforduough his
howown ever,thebuildivi crimptsuerimprovememserene inundedmplleercd the owner-e.
OCC GROUP RFS.UNITS
howerwilleavetie hanien of pa innt iehat he ii noneyem or improeion,far purposef TOTAL:
builJer will have the burden of proving that he did not build or improve(m purpose of
sale.).
❑ I,as ownerof the propmy,emexdusivelymntruting wiN licensed contractarno QTY. PLUMBING PERMIT FEE ROOU ZONE APN
construct the project(Sec.7f1d<,Business and Profcssiom Cale)The Contractors
License Lawdoesnotapplytoanowner.fpmpenywhobuildsmimprovathereogPERMIT ISSUANCEand �dU
whocoulnum for such pmjectswithacontmctor(s)licensedpunuaitothe Conimctors AI'IER-DRAIN&VENT-WATER(EA)
License law. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for dua mason BACK MOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date MPIiNRECEIPT p
. DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COSATION DECLARATION SCHOOL TAX YN
❑ Ihcrcby affmrm thatlhaveacenifiwm ofcansenuo selGinsum,orecenificam of RFCE1PTa
Workers'Compenmtion Insurance or acertified copy themef(Sec.3800,Lab C.)which FIXTURES-PCR TRAP PARK FEE Y N
rs all employee's under this pcnniv Gp5-EA.SYSTEM-I INC.0 OUTLETS
RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS- A---4?; .OVBIt4(BA)- PfANCHECK FEE
❑ Certified copy is hereby(monamed.
❑ Certified copy is filed with the city inspection division. LWASTE INTIiRC OR GRADING FEL
CERTIFICATE OF EXEMPTION FROM WORKERS' MT �COMPENSATION INSURANCE I SOILS LIE
(This sationnad not hcompleted ifNe permit isforone hundred dollars(EI00) SS ENERGY FEE
orleas.)I certify that in the vertonmance ofNe workfor which this permit is issued,lahall L)/' NT .L CTR -
net employ any person in any mmmer so ns to become subject to the Workers PAID
Z Comperealionlawsn(Califomia. Date WATER SYSTEM/IREATINO - o0 Date Receipt#
Applicant
C) NOTICE TO APPLICANT:IL atter making this Cerificmeof Esemption.youxhauld NEW RESIDENTIAL PLMEL SQ.FT. TOTAL:
,w+ V) become subject to the Worker's Compensation provisions of the labor Cale,you must
r.--t forthwith comply with such provisions or this permit shall he clamed revoked. BUILDING FEE
w z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hemhy affirm that there is a construction lending agency for Ne performance of
the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC IEE
V Lenders Name
~F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE eD
{U1 certify that I have read this application and suits that Ne above information is MECHANICAL FEE
correct.I agree to comply with all city and county ordinances and store laws existing to PERMIT ISSUANCE
En buildingeonstmction,and hereby authorixempmsemmeesofthis city to cnterupon the
U abuve-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hermlexs the City of Cupertino against
Ilabilities,judgmenu,cosu and expenses which may in any way ecemengairuueld City AIR HANDLING UNIT(TO 10,000 CFM)
in
a Permit.he graming ofthis peit. 1 AIR HANDLING UNIT(OVER 10,000 CFM)
A&Sil I.-re-93
Signature of plicatNC cmr Date EXIIAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Fsfi"BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defneo by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: 6�
Cade,Section 255J2(e)?
ElY El VENTILATION FAN(SINGLE RESID)
❑
BOILER-COMP(3HP OR 100,000 BTI!) pISSUANCE DATE
Will the aemumntorfuum building by the Bay Are. it Quality Manageichment
ant r A ! D
•
hazardous air conmminems ea defined by the Bey Arcn Air Quality Management BOILER-COW(OVER 1(10,000 BTU)
DistnaT �Ip 1 Q '1
❑Yes 13H.No NEW RESIDENTIAL MECSQ.FT. (N8 MAY 1 1993 wr
1 have read the hazardous mourials requirements under Chapter 6.95 of the
California health&Safety Code,Sections 25505.25533 and 25536. I understand that CI I Y Uh W ren l uvaJ
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the mquirements which must be met poor tat 1...of a Certificate of
Occupancy. lam
Dwner,or authorized ager Date TOTAL: ISSUED BY: �I V
s'