25428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'mpno.a.CTIFI7,AL PERMrYNQ
APPLICATION/PERMIT PLUMBING-MECHANICAL 25428
BUILDING DIVISION BUILDING PROJF.(,r IDENTIFICATION
y S: SANITARY NO. APPLI6 IONS BMIITALDA'IE
Pab U, S I pt UNIT# LOT#
OWNERS AME: PHONE: CONTRACTOR'S NAME: LIC NO: O NIC
CONT OL
d ben - R�o.4 r. El 73` 0
ARCIII'I ECT/ENGINEER: LIC NO: ADDRESS:
S r P•
COMI'ACI'M a r�ylt /I�Pj{ONE: QTY. ELECTRIC PF;RMIT FEE BUILDING PERMIT INFO
I'��• BLDG EL I'UUM}t moll
I PERMIT ISSUANCE NTj(`
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDENTIAL BDISCRII'I N
e z 7 I hereby affirm Nat l am licensed underprovisionsof Chapter9 mmer
(comingwilh
w OOO Section]000)nf Divisom3 ofthe Business and Professions Calc,and my license is in PANELS 4�Any �N4
full forte and effect.
aZ41 Licenve Class Lic.If UPT0200AMF5 j
y<E Date Commit 201-I000 AMPS SQ.FT.FLOOR AREA
Fo,Z ARCIIrrECTS DECLARATION OVER 1000 AMPS
If Fj
ZOm— L understand my plans shall be used as public acord,
oy-o
W SIGNS ELECTRICAL ��4
QYjLiccued l'n+!sionvl
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
C,U (hereby air,.that 1 am esempl fano the Contractor's License Law for the
'31+-y following reason.(Section 7031.5.Business and Professions Cade:Any city or county TE-MP.METER OR POLE INST.
F�-O� which"aims a permit to construct,alter,improve,demolish,or repair any suvctum
f�}5. prior to its issuance.also requires the applicant forsach pennot ileasigned suimment POWER DEVICES
K W Q that he is licensed poomanotto IM1e provisions of the Coolant s License Law(Chapter VALUATI N
aao� 9 em with 7M)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
(commencing �
,Zy o tho 7031. by
yaNerefromnt f the bmiafomheascgedcxcmpioo. civil
of UTLEI'S-SWITCHES-FI%TURES
FZ< not more
than five
undredicamfoTepermit subjects Nc aPPlicant toacivil penehy of
Jp
G Imorc than Rvc hundred Mllars(5500). NEW RESIDENTIAL ELECTS _SQ.FT. STORMS TYPECONSTRUCION
K—Po n❑ 1.oxowneroHhepropcny.ormyemployeeswithwagesaslheirsolecomWnsution,
a3- will do the work,and the structure isnot imendclmoffemd for sale(Sec. Business
and Profeevion.s Code:The Commetor's License Law does not apply to an owner of
propeny wbohuilds or improveathereon.an l whodo<s xu<h wmkhhnse for lhrmgh hlx
owamuda,cecprwIf,
Nal such impmvemenlaarcnol inaentledor offered lornele. OCC.GROUP RES.UNI'T'S
however.the building orimprovement is sold within one year of completion,the owner-
builder will hove the burden of pravimg Ibat he did not build or improve for purprne of
IO')' PLUMBING PERMIT FEE FLOOD ZONE APN
[:I Las owncrrfthepropcny.amesdusively commning wird liaruedconwnorsto QTY.
construct the project Sor.71Ha,Business and Professions Codi The Contractor's
License Law dcesnot apply manownerofptepnY whobuildsrri _���t111ee .gn ER ^S CE
whocontmcts forsu<hprojects with acommetor(s)Licensed pm a. amt . 0�an'd' t k p
License Law. �If1 ALTER'-'b �AlTER EA) FEE SUMMARY
❑ Iamexemptoader Sec. .B PCf 'awn I BAEKI�W �O E OUTSIDE TEil
SANITARY Y N
Owner Date DR D. RECHIVI'#
WORKMAN COMPENSATION DECLARATtNN y SC110OLTAX Y��j
p +WMRAPREClill'1'#
Nnrkcrs Cnmpcnsatiun lnxurunccnraanl7ed copy ahercoT(Secech PARK FEE YN
covers all co b ee's under NisPc^n'iGAS-EA.SYSTEM-1 INC.gOUTLETS RECEITN
PolBUILDING DIVISION FEES
Comp N
Company GAS-EA.SYSTEM-OVER 4(G) PLANCIIECK FEF.
❑ Certified copy ishemby filed
the city
d.
❑ Ccnifid copy is filed wird the city inspection division. GREASFJINDUSTRL WASIIl INTf3RCF..1'1'00. GRADING FEE
CERTIFICATE OF EEIMMONFROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE -
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM G.200FT. ENERGY FEE 2
orlms.) fl 17
p
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR O /_ '7
not employ any person m my mane,nn y t fie, Vecl m the Workers PAID 1� ��7 OQ
Compensation laws of Califomyja�1 IT ac r 17 WATER SYSTEMTREATING (late Rccnpt
Q z Appli<nnl MA d+.<+ �#��t—
C) NOTICE 10 APPLICANT:If.Offer making Nis Certificate of Exemption,you should NEWRESIDENTIALPI.MB, SQ.FT. 'PO'I'AL:
` heconm sobbed to the Worker's Compensation provisions of the Labor Code,you must BUILDINGFEE
a > forthwith comply with such provisions or this permit shall be deemed revoked.
C (, CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby offireadogd n,is a construction lending agency for the performance of
U C) the work for which this permit is issued(Sec.3090,Civ.C.) L ELECTRIC FEE
Lender's Name
0 F lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING ME
U I certify that 1 have read this application and suite that the above information is MF,CHANICAL
correct.l agree it)comply with all city and county ordinances and sane laws relating to PERMIT ISSUANCE
F' N tooddingeonstrucaion,and hereby authorize representatives ofthis city loemer upon the CONS'IRUCTIONTAX
(� z aMwe+nnvioned propeny for inspection purposes. ALTER OR ADD TO MECIL
I c)agree to save,indemnify and keep harmless the Ci penino against
liubilit.s,judgmens,a N waleaperse—In,hmayinany yaccrueagnind,n id City AIR HANDLING UNIT(TO 10.000 CFM)
iacotis luenceofl 8r lingoflhispermit. 4
1� AIR HANDLING UNIT(OVER 10,0110 CFM)
et dAppBca t/Comraaor 7 Datc EXHAUST HOOU(W/DUCI)
PAID
HAZARDODS MATERIALS DISC SURE HEATING UNIT CPD 100,000 BTL) Date ReeciptIs
Will the applicant or future building occupant sate o le aaardoux maerial HEATING UNIT OVER 100,000 BTU) TOTAL:
fill n
m defined by the Cupertino Municipal Cm ,Chaper 9.12, HwIN and Safety
Cade,Section 25532(a)° VENTILATION PAN(SINGLE RPS1D)
❑Yi s IV. ISSUANCE DATE
Will th<u Iicantorfatme building ant ume tordeviceswhich emit BOILER-COMP(31IPORI0(L"BTU)
PP gbyth geaAir P A 9.D
nnlous air onnmminnnts m defined by the Be,Area Air Quality Management BOILER-COMP(OVER IINI,gq BTU) P1
rml J...___,,,///
v ❑Ycs ) No NEW RESIDENTIAL MI-CII. SQ.FT. SEP .a
.�: ///���` r d 1993
have read the laccurdSafety
de,materials re,ummem5505,25533 under Chapter erm d the
California Health&Safety Code,Sections 25505,25573 and 25534. I understand that �s y
ifthe building does not curecally have aenant.that it is my responsibility to notify the V11 1 Vf L.uf� 1 IYIJ
Occupant of Nc requirements which must be met prim to issuance of a Certificate of
a<avamer. 15� �'/��
Owner m andmiud agent Date ISSUED BY: tib
OFFICE
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