25804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO bauji,ixurou-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. _ 25804
BUILDING DIVISION - BUILDING PROJECTIDENTIFICATION
BUILIING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
nIY�`/Cl�xf.�YA}�_v+• LOT r (�
OW � ME: 1 ' COCfOR'SL110. LIC NO:
N/C CONTROL#
AR ECIDENGINEER: - LIC NO: AD ESS: ❑
CONTACT: PRONE: a IIUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
PERMITISSUANCL' �]7� El 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAI. �\
QWz I hereby affirm list lam licensed underprovisions of Chopmr9cnm
( mencing with LOB DESCRIPTION
Section elaef dDlvixinn3of We Nosiness end Professions Code.and my license is in ` PANELS
full forte and efre<t.
license Class Lic.p UPT02W AMPS
h ti arae Commmor 201-Im10 AMPS
7.OrnZ ARCHITECPS DECLARATION OVER 1000 AMPS SQ.PI'.FLOOR AREA EISQ.PT.
O Z—n 1 understand my pians shall he used as public records.
P 11 SIGNS ELECTRICAL
9g Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'MISC.
Xb. I hereby affnd that I am exempt from the Commmors License Law for the
tss3tr-m following reason. 7031.5,Business and Professions Code:An t t TEMP.METER OR POLE INS r IV e 1
I= O Any couny n tl\VY
m� which requires a pemtit to construct,alleq improve,demolish,or repair any structure f .
Wykto its issuance,also the applicant for such ,milt fileasimed malcoml POWER DEVICES
prior quirts pp pc g
O that)(Com islicensedwith Section
Provisions the Contmetnrs License Law(Chapter r` l aI I
s e 1)(CommencingingwiWSenion Tln01 a Division 3ofthe Business and Professions Code) SWIMMING POOL F:LECIRIC 1 VA DATION
or that he is exmnpuhemliom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXT RES
F-Z¢ Scetio-'ban
any died its this $permitsubjects W<uPPlicannnecivilpenalty of
EIAT
'CZ n rethan five M1unJrtd it this
(5500). NEW RESIDENTIAL ELECR
d,asnwnernfthe Prnperty�ormyemFlloyaswith wegesmtheirsolecompensation, STORIES TYPE CONSTRUCTION
a willd a work,amhhe structure is not intended or offered forsale(See,7044,Business
and Professions Code:The Commcmes License Law does not apply 1.an owns,of
propertywhobuildsnrimproves thereon,and whodoessuchwork himselforthroughhis OCG GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for sale.If,
however,tiro huildingor improvement is sold is thin one year of completion,the owner-
builderwillhavethehurdenofproving that he did not build or improve for purpose of 1
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las me protect
(Sec.704 nm Business
and Professions
C l e)Theonuennn's
nmerve, the project(Sec.7044,raciness end Professions Coimprov sOmmma rand PERMITISSUANCE
License Law does not applyct an owner mmemmay who builds orimpro the Comm a and
License Law.
for such projects with aconvacmr(s)licensed pursuanuo the Comwnore
License Law. ALTER-DRAIN&VENT-WATER(EA) FCC SUMMARY
❑ 1 nm exempt under Sec. ,B&P C far this reason BACK PLOW PROTECT.DEVICE d'-S
SANITARY Y N
Owner Data RECEIPT'#
• DRAINS-FLUOR,ROOF.AREA,:OND.
WORKMAN COMPENSATION orco DECLARATION SCHOOL TAX Y N
❑ era Coyuffirmthn Insuvuoarlifwm ofconunuord(Snsure,or Lab C.)c which FIXTURES RECEIPT#
Workers'Cnmpenwtionlnsnrentt nraunificd copy thereof(Su.38f0,lab C.)which PARK FEE YN
coven all employee's under this portion. GAS-EA.SYSTEM-I INC.4 OUTLET'S RECEIPT 0-
Policy# BUILDING DIVISION FEES
Company GAS-HA.SYST'12M-OVER 4 CA) PLANCHECK PEE
❑ Cenilied copy is hereby famished.
❑ CerifieJ copy is Bled with the city inspection division. GREASERNDUSTRL WASIM INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This auction need not be completed ifthe permit is for one hundred dollan(EI00) SEWER-SANITARY-STORM M.200Ff. ENERGY FEE
of less.)
I Cut,ity tIndia lire Performance of the work for Much this permit is issued,I shall WATER IIEATF.R WNENT(ELF.CTR
not employ any person in any manner so is to become subject to the Worker% PAID
Compensationlawsof California. Date WATER SYSTEM/IREATINGZ Applicant Data Rueiptp
Z O NOTICE T'O APPLICANT:If,mftcrmakin II Certificate of Ea,m f n
g tis P m ,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
r . become subject CopmWt Workers Compensation carrisi"I be he LeeneCode oked. most
R 7 foMwith comply with such provisions onhis permit shall be domed revoked. BUILDING PER
W
z CONSTRUCTION LENDING AGENCY SEISMIC PER
•^J Iherebyoffrnu Wanhem is a...struclionlendingegrncy for the performance of TOTAL: ELECTRIC PER
O the work for which this Permit is issued(Sec.309'!,Civ.CJ
Lender's Name v
0 F Lender's Address QTY, MECHANICALPERMIT FET.
PLUMBINGME
U 1 Certify that L have read this application and stale that the above information is
Como.l agree to comply with all city and county ordinances and state lows relating to PERMIT ISSUANCE: MECHANICAL.FEE
Lo) building construction.and hereby authorize representativesefthis city to enteruponthe CONSTRUCTION TAX
U `Z above-mentioned property for inspection purposes. ALTER OR ADD I'O MECI1,
(We)agree to save,indemnify and keep harmless the City of Cupertino against
IiLbilitax,judgmems,casts and expenses which may in any way aurae against said City AIR HANDLING UNIT DO 10.000 CFM)
,Itcorse ee of the granting of this permit.
AIR HANDLING UNIT(OVER 10.00(1 CPM)
nature of ApplicandCmntrecmr a EXHAUSTHOOD(W/DULT)
PAID
I IAZARD MATERIALS DISCLOSURE HEATING UNIT'(TO 100,11011 RTI) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T'O'TAL:
Code,3ee11On 25532(n)'!
Cl Yes ❑No VENTILATION PAN(SINGLE REBID)
Will thwPpli<ent orfumrebuildingmccupam uuequipmenmrdevices whicM1cmit
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminrins as defined by the Bay Art.Air Quality Management BOILER-COME(OVER 100,0110 BTU)
Diatri
❑ P A
Yes ❑No NEW RCSIOENI'IAI.MF.CH. SQ.PT.
1 have read the hazardous materials requirements under Chapter 6.95 of Ne
Culiromia Health&Safety Code.Sections 25505,25533 unit 25534, lundersmndthat NOV 241993
if the building Jces nut eurenJy have a anent,that it ix my reapmmihility W notify We
occupant of the requirements which must be met prior 10 issuattce mf a Crnificare of /�
Occupancy. V �t :
Owner or amh vrized agent Date TOTAL: ISSUED BY:
OFFICE