25688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO. RIr1.DiNc 0:EC`IRIA PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL !�C O C
BUILDING DIVISION LLUILDINI:PROJE(.1'IDENI'1 F'1CATION LJ OL`
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMDTAL DATI'.
/ x .UNIT# I.OT'# `� (.
WN NA �PHDNF, �x ..r O CQ A O AME: LIC NO:
SuC.�GGI �G1/5 /s N/C COMROLp
j�A C i ''R°NGINIiIER: LIC NO: ADORE 5: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RE.SIDENTIAh )OB pFSCRII'I'ION
p w 2 I hereby affirm than l am licensed underplovisions ofChipta9(commencing with
P0{�0❑ gtttion](KK)I^f Di,oamdqof the smalitnd Professions Code,and my license is in PANELS
TUU fall nsecand Y
FZ.y
License cClass Lic.N LfT /may/' UI"1'0210AMI'S a /
to<°' Dam Cumracmr / 201-1000 AMPS
FyL ARCHITECTS DECLARATION SQ.Fr.FLOOR AREA $/SQ.FT.
ZOrn- IundccslunJ my plans xM1ull be usd us public recoNa. OVER IBRO AMPS
OZ-'C
SIGNS ELECTRICAL
Qy�•d Licensal Professional
�yd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �-
OiU I hemhy affirm Ihzt 1 an exempt from he Cn deacon's License Luw for the
�3u-vF-i following mason.(Section 7033.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F¢OQ which enquires a permit to ecommim.deer,improve,demolish,or repai.any..vaunt
y}5 p6ormitsiasuance,also re he licam forsuch ,1..file.signed statement POWER DEVICES It
�tyy quires p prtni gn
C O Thal he is licensed pursuant u the provisions of the Contractor's Litems Lao,(Chapter
SW IMMLYG POOL ELECTRIC
dWM 9(commencing isxempt tSeaton TaW)af Division Sof the Business and Professions Code) 1y1��T10N
Ix-ZZ or that Sectioheis15 byahaefmmnnd the basperisfonheas the
exemption.Any violation of
FZQ Section 7031 by any applicantfnrapermit wbjccts the applicamwacivil penalty of OUTLErE-SWITCHES-FIXTURES '
SsC not more than five hundred Jnllws(SSW). 11
NEWRESIDUbFGALELECIit _ Q:F1'. ] 1 YI'Ii CONSTRUCTION
CFce ❑ I,mownerofthepropny,ormympil eeswwwagesathelrsolecompensaion,
W 22 will do the work,and the suuaure is not intended or offered for sale(Sec.]UT4,Business
unit Profess.....Core,The C..arunoda License I.aw does nnI apply In on owner of
propeny who builds or improves themon,and who does such work himself or through his
nemployces.provided that such impowecnem anot intendedoroffered forsale.If, OCC.GROUP RIS.UNITS
m
however.the building or improvement is sold within one year ofasmpletion,the owner. TOTAL:
builder will have the harden of proving Bust he did not build or improve for purpose of
sale.).
[3I.as nwcam
nefthe property,aexclusively contracting with liceussedcuw
neton in
QTY. PLUMBING PERMIT FEE FLUOD ZONIi APN
L..strict the project(Sec.9044,Business and Professions Crile:)The Contractor's
icense haw d«snot apply..wuswnerofProperty whnhuildsnr Improves thereon,and PERMITISSUANCE
who commets for such Imbeds with acantmnm(s)licensed pursuanuethe Com alm'S ALTER-DNAIN&Vf§YT-WATER
License Law. (EA) FEE SUMMARY
❑ I am exempt undef Sce. ,B&PC for this mason IigCK PLOW pR0'1'I!GT.DEVICE OUTSIDE;FEES
SANITARY YN
Owner Date RECIiIPTa
DRAINS-FLOOR.ROOF AREA.0 ND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IM1creby afEnn lhm lhxvevccnitiwm ofnmsenun self-insure,oracenificam of FIXTURE S-PER TRAP R[CEIPfp
Worker.'Compensation Insurance ora eenified copy thereof(See.JP W,Lab CJ which PARK FEE Y N
coven aIle hi. REcl:l"#
toaGAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION PEPS
Policy p
Company d eiL GAS-EA.SYSTEM OVER 4 IEA) PLANCHECK FEE
❑ SOnifcd co is herewithiby i,city
CenifieJ copy is fled with the city inspection division. GRFASFJINDUSTRI.WASTE INTERCEPTOR GRADING ITE
CF.R'I HICAT E OF EXEMPTION FROM WORKERS' GREASE rIRAP SOILS Pfili
COMPENSATION INSURANCE
(This srtionned not be completed Via,permit is fortune hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. RNFOY FIVE
or less.)
I cenify that in the Performance ofdhe work for which this permit is issued,l shall WATER HEATER WNENTIPLECTR
nm employ any person m any mariner so as m become subject m the Workers PAID
Compenswinnlawsof Califomia. Dade WATER SYSTEM/TREATING' Date Receipt#
z Afflicum
z2 NOTICE 10 APPLICANT:If.after making this Cenificme of Exemption.you should NEW REST DENTAL PLMB. SQ.IT. or
I-+ V] become oubjeset the Worker's Compensation Provisions of the labor Cade.you must
1a-' ? forthwith comply with such provisions or this permluhall be deemed invoked. BUILDING FEE
C F CONSTRUCTION LENDING AGENCY SEISMIC FIVE
V Z I hereby affirm that hem is a construction lending agency for the performance of TOTAL a
� ELECTRIC FEE
O the work for whichthis permit ix issued(See3097,Civ.C.)
Lenders Name
TY. MECHANICAL PERMIT FEE PLUMBING FEE
O F I<ndIv Address Q
1..) I cenify that I have read this application and stem that the above information is MECHANICAL FEE
meta. Iugrcc to comply with all city and county ordinances and mita..laws relating.. PERMIT ISSUANCE
haildiagconstruction.and hereby authorimmpresenmiives ofths cy o r up
(n iittenter n me CONSTRUCTION TAX
U above-me).,me propertyfarit keep
ALTER OR ADD TOMECII.
(We)agree to nave,indemnify and kttp M1armless the City of Cupertino agaivt
liabiliti 'ud� snit,,pexis and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO 10,000CFM)
co ofthe of lti Emit.
/—`�J/, AIR HANDLING UNIT(OVER 10d"CFM)
SI marc of Applicun/Cmmratur de EXHAUST HDOD(WNUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.008 BTU) Date Receipt#
Will the applicam or future building occupant store or handle hazardsi,material
as defined by he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety II EATING UNIT(OVER 1 W,BW BTU) TOTAL:
Code,Smi El Via, ep VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISS ANCE DATE
Will the applicant m future buildingnccupnot useequipmem ordevices which emit BOILER-COMP(3IIP OR Had,000 BTU) P p 1
haradom air comaninanu as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER IWd%10 BTU) M 1
District? 'JAN 1Z, 1996
❑Yea ❑No NEW RESIDENTIAL MECI{, SQ.FT.
1 have read the harmdous materials requimments under Chapter 6.95 of the ,.,�
California Health& .viersty de,which
Sec[ias.25 metm5J3and25534. 1.Certificate of
CITY OF CUFENfINCA'tX _
ifthchuiliingdoc t ally have u lemmmh[hat h ix my responsibility to notify the
capon[ the ygi�s which man t prior tu ismante of a Cenificam of
wrier n authomed agent Dade TOTAL: ISSUED BY:
OFFICE