25585 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU"
" ' ' rr:Rsur NG.
ny 0"C mvISION APPLICATION/PERMIT PLUMB NG 2 5 5 8
_ -,BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I SANITARY,O. APPLICATION SUBMITTAL DA
4! {-�' � �� k V O \ �Tlill (C ITp CDI���.,,IV�(N Sir V(' L/(U/ �•y �1 ��
LOT'p 1
Ow S;AAIJ.j� -��_ P N — CONTjigCfOR' i fE: ���Irl LICNO: �I NIC CONDROL4
•\HCHITEC'fIHNGINELR: LIC NO: .\(c, /a..J O'�C_!\•Y�VI(/.ESS El
CONTACT: PHONE: so- ry•,.ty"x.w�a..a.�..-a e:yi,r1+ti:g;::�. .-.. a:.' 'BUILDING PERMIT INFO'
.
QT,Y. ,, `"4„?ELECTRIC PERMITm,,'.-i•�, `FEE'i�'
a� // ,sr n/in»uvak%SaN.b'i,,,;vy;,pA.'.gaa5?t..tTF.r,13:SJ 5..1t: nro. BLDG ELECTPLUM MBCH
PERMIT ISSUANCE I El 1:1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ Iherebyuffimtthat lam licensed underprovisionsof Chapier9(commencingwiO
BOO Section 7000)of Division J of the Business and Professions Code.and my license is in PANELS
y [[- full fame and effect w
F-OZ,W License Class Lic.g UPT0200AMPS U `
m<o• Dam Com..,., 201-1001 AMPS
IT.FLOOR AREA $`SQ.FT.
Z�,z ARCHITECTS DECLARATION OVER 1000 AMPS
O Z-C I understand my plans shall be used os public records.
SIGNS ELECTRICAL ^
<, �J Lucnaed Poilessional
=Ine< OWNER-BUILDER DECLARATION SPECIAL CBtCUITMISC. r
C. 1 hereby affirm the,1 am exempt from the Canrvctors Lt..Law for the
oc 3 u n following ruvon.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE TNST. - - - -
1_�O3 which require.[a Permit to con[Wm,alter.improve,demolish.or repair any structure �, I,'J 'i T E J']
e L3Y� prior to its issuance also requires theapplicant forsuch permit to file^signed statement POWER DEVICES
a d G 0
that he is licensed pursuant to the provisions of the Contractors License law(Chapter SWIMMING POOL ELECTRIC
�O(t 9(commencing with Section 7080)of Division J ofthe Business and Professions Code) 'ALL,
.1 that he is exempt therefrom and the basis for the alleged exemption.Any violation.( OIITLEI'S-SWITCHES FIXTURES —
FZQ Section 7031.5 by any applicant for a permit subjects the applicant m a civil Jimmy of
=0 not more than Eve hundred dollars(5500). NEW RESIDENTTALELECITt5 FT.
KFS ❑ I.asowneroftheproperV.ormyemployeeswlthwagesmtheirmlecoml radon, Q' STORIES TYPE CONSiRUCDO
will do the work.and the structure is notinundedorof.red forside(See.70a4,11mineas
and Professions Code:The Contractors License law docs not apply to as owner of
propenywho buildsor improves themon,and whodoes swItworkhimselforthrough his
employees,Provided that such improvemems are not intended prof&red Tarsale.IL OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yew ofcompletlon,Oeowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). >'+• `-•�a�
❑ I,xsownerofthepropeny,amexclusivel ractin thlicenudconractorsm QTY''-^t�<'a PLUMBING PERMILi:.<t.•"J\T I.�`W FEE'Yi\'� FLOOD ZONE APN
y con 8wi _ r. '..::..
omarun the project(Sec.7614, ea and Professions Coder
)The Comactanr 0D
Licenseiaw does not applytoanownascrofcro1property whobuilds«improvesHereon,and PERMIT ISSUANCE .l
whocomeacs for such pmjccts with armoractor(s)licensed pursuanuothe Cononcows - - - •-.�
ALTF.R.DRAIN&VENT-WATER IEA) _ - yc•=2 FEE SUMMARY%";L
Licenm Law. .t;rT,'-L
❑ 1 am cacmpl under Sec. .B&P C for Nis rwson n BACK FLOW PROTECT.DEVICE 0 •, <'Y r f UTSID. EF.S
4- SANITARY YN
OwnerDau DRAINS-FLOOR.ROOF.AREA.COND. �CEIFT♦
WORKMAN COMPENSATIONDECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a emificam ofconaem to self-insure.or a cenificam of FIXTURES-PER TRAP RECEI"x
Workeri Compensation Insurance or a certified copy thereof(Sec.3800.Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSIEM-1 INC.J OUTLETS RECEIPT'p
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCIECK FEE
❑ Co ifievimpyishembyfamished.
❑ CernOed copy is filed with the city inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed if Ne pemtit is for one hundred dollars($1010) SEWER-SANITARY-STORM EA.200FT, ENERGY FEE
or Is,,.)
I cenify that in the performance of the work for which Nis Permit is issued,i shall WATER HEATER WNENT/ELECTR
nm employ any person many monster so u to become subject t.the Workeri PAID
Compensationlawsof Califomia. Date WATER SYSTEWUREATING Date Receipt
Q Z NOTICEApplicant NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z NOTICE TO APPLIGWT:ILaferr making this Cenificme of Eacmption,you should
` become subject m the Workers Compensation provisions of the Labor Cole.you must
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
1 [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereb (firm than there s a construction lending a for the rformanc F
'U Z Ya m e C.) a TOTAL QO ELECTRIC FEE
U O the work for which this permit a issued(Sec.3097.Cis.C)
Lender[Name / 'v a^y Z. d"'tisc e o: a t!`y"p' PLUMBING TEE
F 1<nders Addmeaa QTY 'MECHANICAL:PERMIT.�y4," 1 ,..FEE °('
O J I comfy that 1 have read this application and state wt the above information is c e slxas a sin srs _ w5s.�3 a Y
�•' fy correct. la agree to comply with all cit and ordinances and cute laws mlatin to PERMIT ISSUANCE . MECHANICAL FEE
g pd he yon yo 8
VI"' N ahovengconaased construction,and horinspection erepresenutivo of Nis city to corer upon the CONSTRUCTION TAX
Z aboveWe)agree pmpve.indmnify, and purposes. ALTER ORADD TO MECH.
(We)ague to save,indemnify and keep harmless the City of Cupertino against
Ilubilities,judgmcm[.<oss undexTxnuswhich mayinuny way a<cmmgainst said City AIR HANDLING UNIT(TO lO,U(p CFM)
in consequence of the granting or this permit.
AIR HANDLING UNIT(OVER 10.030 CFM))
Signamm of APPlicm Canmwmr Dau EM IAUST HOOD IW/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM,"BTU) Dam Receiptp
Willthe applicm or rummbuilding«cupaw store or handle hmadous nowimal HEATING UNIT(OVER 100.000 BTU) TOTAL: 33- 10
a.dunned by the Corrado.Municipal Code.Chapter 9.12,writhe Health and Safety
Code,Section 25532(u)'I VENTILATION FAN(SINGLE RESID)
❑Yes Vo
,1$StIA,yC60ATE•
Will thea limmnrfuturehuildin tusce menwrdeviceswhichemit BOILLR-COMP(JHP OR IW.IXIO B'N) Y /4 i lJ
Pp Eby then 4rea
M1acvdouv air comamiwnu as Aclined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,B(IU B'TU)
Uiauin'!
❑Yea NEW RESIDENTIAL MECH.—SQ.IT. SEP 27 1993
1 have read the ho wn"o"'' a on'I requiremems under Chapmr h95 of the
Callfomla l lea II Selay Cw as 25505,2557.3 and 25534.1 understand Oat CIII yr uUf CnI IPIV
ifthe builAin• .x rat cu y ays.mmm.that it is my reapamibilitym notify the
ccupant of a 4uirem h must met prim to issuance of a Cenificme of
O,rm ncy
Owner or a ego Dene TOLL: ISSUEDBY: "aN sr`-C-L
OFFICE