25398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIf111.Illi DI.L`EI'HS,AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL f� [ (] p
BUILDING PROJECT IDRN'I'IKICAITION G J J v
BUILDIN%ADDRESS: ^� eI - ,x , + SANITARY NO, APPLICATION SUBMITTAL DATE
l•.//JS) 5 I'Ds'\J 'fY-Y/"/�_Vl/ UNI'I'M hOTp -
t An
10W ERS NAME: PI NE: CO ORIS NAME: - LI NO:
✓v , �L- L w_ I r N/C CONIROLN
RCIfITECI'/' GINISIiR: LIC NO: AN Rf ` ❑
I Lav re o0 U.- 5'ela r
1
:ONTACT: PHONE:" QT'Y. ELECTRIC PERMIT FEEHUII,DING PERMIT INFO
^�+ B� IA P1,41MJ1' MECI
PERMITISSUANCE 'IHJ-_Cxl\(
LICENSED CONTRACI'OR:S DECLARATION APPLIANCES-RESIDENTAl, IDH DF.SCRIPI'ION
omz Ibembymfrmthm l nm licensed under provisionsal'Cltapter9(c+mmeivin,witM1
�zs0E�0 Sealon]000)of Division 3 ofine Business end Professions Cale.nnd my license is in pgNiilS n/
XUU fUll fore'andtffe % DU� �/ ,
(<„-LW License las Lich UPTO200AMPS
,o :)D. am - - Contra 201.1I8N)AMI'S
zOyz ARCHI'TECT'S DECLARATION OVER I"AMPS SQ.PI'.FLOOR AREA $/SQ.IT.
O Z-LI understand mY plans shell he tined as public.,aid"GN�, SIGNS I?LEC7GUCAL
q Llcemed Pmfic,xmnnl
"Wee< OWNER-BUILDER DECLARATION SPECIAL.CIRCUIT/MISC.
0aF 1 haehy affirm that 1 am exempt from the Cnmrucmr's License Law for the
30m following reusaa(Satinn]03 L5,❑usiness unJ lhofessions Code:Any city or county TEMP.METER OR POLP.INS'T.
Pay which requires.permit nt cmeno et,elle"improve,demolish.or repair any'Imemre
,np ,7 Motionless...ce.also requires the applicant far such pe.iuo file o signed statement POWER DEVICE'S
�ej<,0 that he is licensed pursanm m the provisions of the Contractors License Law(Chapter
9(ronmtencio,with section 7000af Division 3oftM1e Bminessund Professions Cade) SWIMMING POOL ELECT RIC VALUATION
' may onhxt he i.exnnpnherefrom and tht basis fnnhe alleged exemption Any viole,.an of OUTLETS-SWITCHFS-
[_zaSection 7031.5 by any applicant fora permit s.bjec.,he.pplicant toe civil penally of I+1%TURIS
not mom then five hundred dollars($500). NEW RLSIDPNTIAL ELECfR _SQ.Ff.
C3I,dsnwncroFlhepmpertynrmycmployecxwith wages us mcirxUlecompensation, STORIES TYPI?CONSTRUCrI N
W22 will do dreamt, it Thesbucmre is not intendedaufferW ounde Xce.1044,Business
and Professions Cade:The Cnmmcmrs Licenu Lew does not apply to vt ownv of
property who builds or improves thereon,and who does such work himsel for through his
oancroplayew,provided that such improvements uranin lnlendedoro[mmil mrsole.If, OCC.GROUP RBS.UNIT'S
however,the building(ir improvement is sold withinone yearofcompledon,f isowner roTOTAL:
builder will have the burden of moving @at he did not build or improve for putpou of
s m). 11
❑ Las owner of the Property,an,exclusively contacting with licensed conmsTnrsm QTY' PLUMBING PERMITI+HE FLOOD ZONE qPN
construct tM1c project(Sec.]044,Business and Professions Cade:)Tlm Comramor's
Licenu torments not applytoarownerofpropenywhobrov
uilds orimpesthemen,and PERMIT ISSUANCE
who contracts for such projects with acomtamoKs)licensed pursunit.11eCmenvoirs pLTIiR-GRAIN 62 _
Llanse I.uw. NE T' ('A) FEC SUMMARY
❑ 1 am exempt under Sec. ,B&P 111,this reason BACK PLOW PROTECT )1iVICE 1 J M UT%IDI: FEES
O Doe = f7 Y YN
DRAINS-FLOOR.ROI ,AREA,COND� I RECEIPTM
Owner WORKMAN COMPENSATION DECLARATION I V I O1.TAX YN
Thereby eff thmlhaveoeertifcam of cmreenut elf-insure,orecenificxm of FIXTURES-PER TRAP RECEIITN
Workers'Compewricn lasumncem.cenifal copy thereof(Sce.3800,Lab C.)whidi P KFI3E Y_N
6`nviera all�cm$$fl.o�Y��g��ef99�'s�u����his permit. RECETPTp
Company-
5 GAS-EA.SYSTEmil INC. BUILDING DIVISION FE
hoax !'A , ✓� �7-T,7
Company GAS-EA.SYSTEM OVER 4 EA) PLANCHIiCK FEE
❑knifed copy is filedherew th he city
CenifeJ copy is fled with he city inspection Jivisiom GRFASFJINWSTRL WASTE INTERCEPTOR GRADING IIiG
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE:
(This melon need not be completed Ban,permit is for one hundred dollars Fl UM) SEWER-SANITARY-STORM EA.200FF. ENERGY FEE
or co.)I
I certify that in the performance mine work for which this permit is issued,)shall WAIER IIEATFR W/VENTPdLEC1R
not employ any person in any manner so as to become subjem to the Workers' PAID
O .� CampensationlasvtmC.lifomia. Date WATER SYSTEM/rREATING Dam Receiptp
Applim nT
z NOTICE 9'0 APPLICANT:If.after making Ibis Certificate or Exemption,you should NEW RESIDENT Ad.PLMB. SQ,17, TOTAL:
F (q become subject to the Workeri Compensation provisions of the Latin Code,you must
? forthwith complywiIh.wrh provisions or this permit shall be deemed,—ked. BUILDING FEE
yQ CONSTRUCTION LENDING AGENCY SHISMIC FEE
Vz Ihcuhyaff,.thanhem is.cmmtmction lending.gemy for be peformncm of
O the wok for which this permit is issued(Sec.3097,Civ.C) TOTAL: _2,)_5T ELECTRIC FEE
D. p I,emder's Name
Lender s Address Q'I'V, MECHANICAL.PERMIT FEE PLUMBING FEE
V 1 cenify that I have read Nis application and start that the above information is f
come[.)agree to comply with all city and county ordinances and suite laws relating to PERMIT ISSUANCE MECHANICAL FEE
b.1clingcomnmunin,and hereby nmhorize representatives of this city to enter upon the
V 'z abovo-memioned property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree m save,indemnify and kap harmless the City of Cmpcnino.,.last
limbi arms,judgments,costs and expemsw which may in any way accrue against said Ci ty A IR I ANGLING UNIT(TO 10."CFM)
ro....a,.ec of the gmitir,of flhis paten,.
AIR HANDLING UNIT(OVER 10,M)CFM)
Si,artmeof Applicam/Comommr Date EXHAUST HOOD(W/DUC'19
PAID
IIAZARDOUS MATERIALS DISCLOSURE 11 PI ING UNITTO 10d"BTU) Date RecciptN
Will the applicant or future building occupant store or handle hazardous mamdm HEATING UNIT(OVER I00,(IfI00TU) TOTAL: ass
us defined by The Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Code,Simeon 25532(x)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 HTU) ISSUANCE DATE
Wusair
ncontammfts as h ffireg by the Bay equipment .alit Manes agch ement /� /�,
hazvdom air conmminums as defined by the Buy Area Air Qualify Management HOLLER-COMP(OVER 100,II(10 BTU) P A I y
�islrita? .
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.pT.
f 1 have read the Safety
Co s mmerials require5533 d 25 Chapter understand
of the
NOV -8 1993
S ifthe Imildr,dhffi Safety Code,ave. s25505,unt,tht itisn responsibility
1uy to randthat
ifine buildi gdas not currently M1aveutenanL)tier it is my responsibilityronotify the +a'
pan f The m rmorecenh hi the met poor at Issuance of a Cervi m of f" CI I Y LA' lgU I- s J
p` r wit�1>'� 1l-Lf-X3
Owner or.ufhorizcd eget Date TOTAL: ISSUED BY:
-
OFFICE