24893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- A.. 'TR ICAL PERMITNO,
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING.MECHANICAL 2 g Q 9 3
BUILDING PROJECT OWN'1'I FICA'[[ON
L 1•�o J
BUILDINGADDRESSSS / SANITARY NO. APPLICATION SUBMITTAL DATE
O ( L' k/OV" UNIT# LOT# 3-2–,_P
OW 'RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL#
o a s
ARCIIITIiCT/E GINEE LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLD# ELECT PLUMB MECH
PERMIT ISSUANCE IITI/I� E] 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. IDB DESCRIPTION
C 2 1 hereby affirm ohm I am licensed underpmvisiwxwChapler 9(commencing with
POO Section VOW)of Division 3 of the Business and Professions Code,anA my license is in PANELS ��
<d 1U11m`1lcCndeffect. ,J^ �a UPIO2WAMP5
Qy I.Icen Clud hlc.p �RR2..KK))ff nn sk--sr �A�
PFn - Dme Contractor 201-IUIt11 AMPS 1-
20v� ARCHITECTS DECLARATION OVER 10f10 AMPS SQ.FT.FLOG ARCA $/SQ.FE
0Z M l understand my plans shall be used as public ascends. SIGNS ELECTRICAL
ayU Ircenud ProfessionalRC
OWNER-BUILDER DECLARATION SPECIAL CIUIT/MISC.
X' yW FFF I hereby toff Bad m at I sm exempt frothe Contractors Litems Law for the
Wfollowing....(Section 7031.5,Bmincmand Professions Code:Any city orcoumy 'TEMP.MRTER OR POLE INST.
a i� which requires a permit to construct,alter,improve,demolish,or repair any structure
2Ct�7 to its issuance,alsorc requires the applicant for such permit rile a signedstatement POWER DEVICES
E prior 9 pP PLo
CC �p 9(Comthat he isncing with went Section
000)the of Division the Convectors Licensel.amas Co ter
�Wp 9ltnnmenaing with Section7W0)nf Dvision7otthe Business and l'mfcsxions Cede) SWIMMING POOL ELECTRIC VALUATION
or don he is exempt therefrom anti the basis for the alleged exemption.Any violation of OIJTLIRS-SWITCHES-PI%TURES (^/`/ /t�
Y Section 7031.5 by anyeppliewl fore proton subjectstheapplicanno u civil penultyof - ,J V 1/
Q not mote than five hundred dollam(5500). IT. IL I ,
K w ❑ I,mowncrofthepmNny,ormyemployeeswithwagesmtheirsolecompcnsmiNEW RFSIDIALon. STORIES TYPE CONSTRUCTION
ywill do the work.snd flesdowmre is not intendedmroffered fsrrale(Sm.V194,Business
and Professions Cade:Me Computers License law does not apply to an owner of
propertywyees,pAsorimprovesthertomanrwho we not intended
tendo himulfedthroughhia \ OCCGROUP RES.UNITS
nemployees,provided thatsuchimprovementsarcnot ewofdroffered fmsole.IL
however,rwill avec a bur den of cmentoving thasolt
he id noneyem or improve
f T
builder will have the burden al proving that he did not buil)or improve for purpose of — DATE
(J I,a,owneroftheprtpeny,nmexclusivelycomratingwitb license-)rnnuunoram QTY, PL ING PERMIT FEC ODZONE APN
construct the project(Sec.7194,Business and Professions Code:)'Me Contractor's
License lswdoesnotapplytoonownerofpro enywhobuildsorimpmvesthereon,end PERMIT ISSUANCE
whucontr.cts forsuch pmjects with.contractors)licensed pursuant o the Conwetors pLIER-GRAIN&VENT WATER IPA)
License Law. FBE SUMMARY
Cl I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE '.q
SANITARY Y—N
-
owner Date DRAINS-FLOOR,ROOF,ARECON D. RECEIPT#
WORKMAN COMPENSATION DECLARATION A, SCHOOLTAX Y
-❑I 1 hereby affirm that 1 have u cenificate of consent to self-insure,or a certificate of RECRIFT#
Workers Compensationlnsumnceoraceniriedcopythereof(Sec.3800,UhCJwhich FIXTURES PER TRAP PARK FEE Y N
I'ulicy p emplPYce�to Wis�pe®IL e--O ./ RECEIPT#
✓✓JJ 77 J 1 7 GAS EA.SYSTEM. INC.
�� BUILDING DIVISION FEES
Company�rr hereby e'n GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cmified copy is filedw with
th,W.
/fid Certified copy is filed witM1 Ne city impaction division. GREASPJINDUSTRL WASTE IMIIiRCTa'fOR
GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS GRPASETRAP SOILS FEE
COMPENSATION INSURANCE
('Phis section need not he complied ifthe permit is for one hundred dollars($10(h SEWER-SANITARY-STORM PA.20BFf. ENERGY FEE
or less.)
I certify that in the pdrmonancenfthe walk for which this permit is issued,Ish.11 WATER HEATER W/VENT/P.LECI'R
not employ any peram in any manner so as to become subject to the Workers' PAID
Compensutionlawsof California. Date WAI'ERSYSTEM)TRFATINO Date Receipt#
� 7–r Applicant
0 NOTICE TO APPLICANT:If.utter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FE TOTAL:
(, U) beromesubject to the Worker's Compensation provision ofthe Labor Code,you must
� > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE Q
O CONSTRUCTION LENDING AGENCY SEISMICFEE a
1 hereby affirm that hem is a construction lending agency for performance of TOTAL: F,LF,CTRIC ME
work for which this permit is issued(Sec.3M7.Civ.C.)
Ide.Name PLUMBING FEE
O UsnJ
Under,Address QTY. MECHANICAL PERMIT' FEF.
I terrify that I have read this application and smm that the above information i,
collect.Ingres mcomplY wiOUAl city and otomy nrdinnnces anti,roto lows rdnting to PERMIT ISSUANCE MSCI IANICAL FEE
buildi ag construction,and hereby authorize representatives of this city to enter upon the
C.) 7 above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitiits,jW is,coma and expenmswhich mayinany way acerae against said Ciry AIR HANDLING UNIT(TO M.0MCFM)
in conmga f the granting of this permit. p p�1
L .2 U2 AIR HANDLING UNIT(OVER I G."CFM)
Sig . p/� .tor Dula EXHAUST'HOOD(W/DULT)
PAID
HAl RDOUS MAI'P.RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as refined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEM ING UNIT(OVER 100,WO BTU) TOTAL.:
Cone,Section 25532(a)7
❑Yes Y.
VCM'11AT10N FAN(SINGER RPSID)
BOILER-COMP OHP OR 100,000 BTU) IISSISU�kN JE.DATE
Will theepplicanterfmare buildingoccup.m uurquipmrnt ordeviceswhichemit Y y�
aft us on
air ctamnanm
its defined by the Bay Area Air Quality Management BOILER-COMP(OVER1011,01M0BTU)
Z., to
❑Yes ❑N NEW RESIDE- ALMECH. SQ.F`F. MAR 2 3 1993
I have read the haz�materials requirements under Chapter 6.95 of the Vll�p''�11t t+r{P 1
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that CITY Ur liUrer1111NV
if the building Aces not currently have a tenant,that it is my responsibility to notify the
.cup ,n mmc which must b,met form,to issuance of a Ce fificate i f
Occup Y. _ _ .x� rs
Own ro orizcJ egen o D.te TOTAL: ISSUED BY:_Ja
OFFICE