25541APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO "unmrsui-P.Lbu rincAUPERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
OIUENI' IFMATION
BUILDING I'RJIrCI'
NO.
n C C ^
G J J a�
BUILDING ADDRESS: //.��
asOto / O r `-arbM UNITN LOT
SANITARY NO.
APPLICATION SUBMITTAALFA
_5CJv7 ��-✓
OW CRS NAMI?: PHONE
�J sir 99 / _ 0 3 7P
CO LIC NO:
NIC
COMfROL p
RCHI'IECI'/FNG L'ER: LIC NOK:
ADDRESS: COW of DO
a Micro place r 64. P.Ioa
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FET?
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
PERMIT ISSUANCE
mZ
00
[ 2
aL
F
.is6yay
r ZOr`rr4
0 Z-Q
Fnh1
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lice se0 underpmvisionsof Chapter9(commeneiagwiN
Smlkm70W)of Divplbm3ofthe Business end Professions Cale. and mylicenx isN
fall force and effect
Liccns la O� IO Lie.# �I �O T, \
Date �Convoctor r`I (-,
APPLIANCES- RESIDENTIAL
PANELS
I UPTO200AMPS
JOB DESCRIPTION
201. 1000 AMPS
ARCIIM=S DECLARATION
1 understand my plans shall be used al; public recmds.
OVER 1000 AMPS
SQ. IT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
4x J
y Q
041,0„
/
j
Licensed Professional
OWNER-BUILDER m
DECLARATION
1 bushy athat I em exemptempt from the Conuunnta License Lew for the
following resson.(Section 7031.5, Business and Professions Code: Any city or county
SPEC.CIRCUTf/MISC.
W
TEMP. METER OR POLE INST.
which requires a permit to construct. alter, Improve, demolish, or repair my structure
�
Wa!
priorto its inuaN
nce, also calcites e applicant for such Permit to file a signed statement
Nat he is licensed prsuant to the provisions of the Contractor's License know (Chapter
9(commencing wish Section 7000) of Division 3 of the Business and Professions Cale)
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
,Mo,
CZ¢
Mo
or that he is mcmpuhetefrom and the basis far Nealleged exemption. My violation of
Section 703 LPermit 5 by my applicant for a peit subjects the applicant to a civil penalty of
not more than five hundred dollars SSW).
❑ I,usowneroHheproperry,ormyemployecswiNwegeautheirsolecampmsetion.STORIES
wµ11 doth,.work, and the someone, is not intended or offered for sale( Sec. 7044, Business
OUTLETS- SWITCHES- PI%TIIRES
NEW RLSIDENTIAL ELECIR-SQ.PL
TYPE CONSTRUCTION
and Professions Cade: The Contractor's Llmme Law does not apply to an owner of
�632-
pmporty who builds or improves thereon, and whudoes such work himeelfor though his
cmployess,pmvidedthat such improvements heart imencedoroffered forsole.IL
however, the building orimpmvemem is said wiflamone yearofcomplction, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
... -
p -
OMFU F II II J
V CCC `�J
.UNITS
I_ R
1
TOTAL:
QTY. PLUMBINGPERMIT FEE
salle.).
❑ I,aaownerofthepropeny,ameaclusivelycontmccingwiNlicensedwntr ionm
construct the project (Sec 7014, Business and Professional Code:) nil Cmnacmda
FLOODZONE
TE
PERMIT ISSUANCE
1
-,
License Lawdoes notapply manownerofproparry whobuildawimprvesihermn,and
who contracts for such projects with a conuacmr(s) licensed pursumOo the Commusn's
License Law.
ALTER (IA)
PEE SUMMARY
❑ I am exempt under Sec. , B & P C for Nis reasonOki
BACK FLOW PROTECT. DEVICE
I E ..
SANITARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION
#RAINS - FLOOR, ROOF, AREA.COND.
RECEIPT#
SCHOOLTAX YN
T2 Ihcrcby affirm thmlhnveocerrif¢are of consenuoselGinaurc, orawrtificem of
Wmkeri Compensation insurance or a terrified copy thereof (Sm. 3900, Lab C.) which
RECEIPTM
FIXTURES -PER TRAP
PARK FEE Y N
_
coven all moplpgee'gunder this � remitt. C1 7
policy p ��//NN GG t
0
GAS - EA. SYSTEMA INC. 4 OUTLETS
BUILDING DI IST FEES
Co Pent "' Pws .a4<
Certified copy is hereby finished.
GAS- EA. SYSTEM -OVER 4(CA)
PLANCHECK FEE
GREASMNDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CenifiW copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GREASE3'RAP
SOILS FEE
SEWER- SANITARY -STORM HA. 200FT.
ENERGY FIDE
(This xaiontumvimt be completed if Ne permit is forces, hurWrcl dollars ($000)
Or lers.)
WATER HEATER WIVENT/ELECIR
I certify that in the performance of the work for which this permit is moan, i shall
not employ any person in my manner so as to become subject to the Workers '
PAID
Q z
0
Compevatme awsof Califomis. Date
Applicant
NOTICF,TO APPLICANT: IL after making this Cerrificrm of Exemption, you should
WATER SYMEM/(REATING
NEW RESIDENTIAL PLMB. SQ. PT.
Data Receipt#
TOTAL
Ft l
a;
becomeaubject to the Winker', Compensation pomisiau of Bre labor Cade, you most
forthwith comply with such provisions or this point shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
z
U O�+
t•`
U z
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sm. 3097, Civ. C.)
Lender's Name
V
TRIC FEE 3�
Lenders Address
certify that 1 have teed Nis application ty sun Net the above iwareladon is
cnrtua. lagrec nsaomply with all city and county oNinences andatate laws relating to
building construction, and hereby authoriu tepresenutves ufthis city toenter upon theTRUCTION
above-mentioned property for inspection purposes.ALTERORADDTOMECH(We)
QTY, MECHANICALU1
MBING FEE
MPERMITFFE
PERMIT ISSUANCEHANICAL
PCE
TAX
agate mrve, indemnify and keep hmmlcss Ne City of C.,mur n against
hich may in my way meme almostt kind Cpity7
liabilities,' a ts, cosulm
AIR HANDLING UNIT CFOen
sl�aae
co the gru q-IJ"/.JAIRHANDLING
/
UNIT(OV
Signa ueafApplicam/Contmcclar Data
MIAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt #
HEATING UNIT(TO IO ,(M BTU)
W ill the applicant or furore building occupant store or handle haxmdom mmerial
fin
as deed by the Cupertino Municipal Cade, Chapin 9.12, and Ne Health and Safety
HEATING UNIT (OVER 100,00) BTTD
b
TOTAL �-
VENTILATION FAN (SINGLE, RESID)
I
Cale. Section 25532D)7
❑yes�No
which nt
Will lair
BOILER - COMP (3HP OR I W,WO BTU)
BOILER- COMP(OVCR 100,000 BTU)
conmerm nta as defined by the ay Ares A, Quality Managemees
haaardwa air cmiminnts ea defined by the Ray Arm Air Quuliry Managemem
D9tritly
!/,�
El Yes /�gym•"
It... read the havmdcus materials requirements under Chapter 6.95 of the
sp-C p 13 1993
1
NEW RISIDI'NTIAL MECH. SQ. Ff.
California Health & Safety Cade, Sections 25505, 25533 and 25534, 1 underatand that
a
ifthebu'drtg' sd m=xn0yha leant, that it is nay, responsibility to notify the
.
oec a the quirements hich stnbe met prior m issuance of n Certificate of
INSPECTION DEPARTMENT
---
�: 1 I 54,F3
BLDG.
NN
ISSUED BY:� B C�rI/%✓/4-4��-f
Ow
r or authodml agent 1 Dale
TOTAL: -
dOFFICE~
-