25753oWC)CI--
azW
Nardi
z On
aO�PUQoz-C
E�
�}e
b - ZS
E�2
i3=
z
z
C
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO N11ILD1NfrRrFCTRTCAI.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MIECHANICA11
NOR . DING PROJECTIDENTIFICATION
PERMIT NO.
2575 C C
GJ J
BUILDINGADDRF.SS:
0 S.Tt U�IU s MIEN K T3�rV D • DTN
SANITARY NO.
APPLICATION SUBMTITAL DATA.
LG in
OWNERS NAME: PIIONF.:
CONfRACfORS NA.` C
UC �CNO���r
N/C
CON [R LN
A_7AY'KtSEER: HOR.�t LIC NO
[�
ADDRESS: IVl uloc
„1s SJ 15�7�
'ONTAC'I': PHONE:
_
E' JIU W�`� y3Y-16676
[ a A ,
Q•IM c t L ELECTRIC PERMIT, ` FEg
i
UILDINO PERMIT INFO
gf DCA ELECy PLUMB CH
PSP{ yVS�`
PERMIT ISSUANCE —
LICENSED CONTRACTOR'S DECLARAT[ON
I hereby affirm that l am licensed urderprovisionsofChapear9(commencing with
Section 70sup of Division 3 of the Business and Professions Code, and my license is in
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
ME fume and effect
j Licema,MEmor Class Lic.p
UP T0200 AMPS
Date Conuactor =
201 - 1000 AMPS
OVER 1000 AMPS
ARC(IITECFS DECLA AUON CCAJS!n(X*Pa
1 undersand my plans shell Is, used as public records. N
SQ, FT. FLOOR AREA $/SQ. FT.
S �
.7
SIGNS ELECTRICAL
Licensed Professimnul
-
OWNER -BUILD ER DECLARATION
SPECIAL CIRNIT/MISC.
• 1 affirm NInt exempt 1 Iexempt from the Connector's License Law for the
TEMP, METER OR POLE EJST.
us
t followingng muster. (Section 703 1.5, Business and Profession Cade: Any city or
structure
which itsiwis a panni[ ic construct,eralteo improve, Demolish, fi repair any smetu it
• its Ne penni0m signed statement
POWER DEVICES
In., he
thatheisncingwced pursuantro the)ofDiomof the Ce Business License Isco(Chaps)
provisions Lice
9(commeis (commencing with Professions Code)
Division Sof theBusinessexemption.
SWIMMING POOL ELECTRIC
VALUATION
and
or Net he is exempt anti the Weis for the alleged exemption. Amyvionnonof
Sermon ]031.5 by any applicantforn hermit subjects the applicannoacivil penalty of
not mos in. Ove hundred dollars($500).
C3I,asownernOhepMparty,ormyemployeeswithwagesnstheirsolec.stento[ion,
� �0
J'S,
1.
OUTLETS - SWITCHES - FIXTURES ��
NEWRESIDE, ALELECTR_SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the werk,and ihesuucture is not intended orofbered for sale (Sec.]044, Business
and Professions Cale: The Contmaorx U. law does not apply to an owner of
tastCC.
property who bei Id s nr improves thereon, and who does such work hi msel f or through his
ownemployees,provided that. such improvementvtmnm ince dedoroffered burials. If,
U
RFS UNI IS
however, the building or improvement is sold within one year of completion, Ne owner-
builderwillhavetheburdenofproving that he did not build or improve for purpose of
talc).
❑ I, Isowner offiepropcny, umexclusively contracting with licensed contraromt0
T 0 T
sIV TmovH
N
QTY.+� : PLUMBING PERMIT P.I
concoct the project (Sec. 7044, Business and permission Codd:) The Contractor's
License law does not applym anownernfproperty who builds or improves thereon,and
PERMIT ISSUANCE
who contracts for such procem with a commetor(s) licensed pursuant to the Contractor's
License l,aw.
gCf?R-DRAINffi VENT (EA )
FEE SUMMARY
-
❑ I am exempt under Sa. , B & P C for Nis meson
BACK FLOW PROTECT, DEVICE
OUTSIDE
MES
SANITARY YN
Owned Dote
DRAINS- FLOOR, ROOF. AREA, COND.
W ORKMAN COMPENSATION DECLARATION
❑Thereby affirm rhatlheve ecenifiam of cnnsennn selGinsure, oracmifictieof
Workers Compenxationlnsumneamrucenifiedcopythereof(Sec.3SW,Lab C.)which
SCHOOLTAX y110EIPTN N
RUClin". Ji
FlXTI1RE5-PIiR TRAP
PARK FEE Y N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
covers all employee's under this permit.
Policyp
RIIFFFFF N
BUILDING DIVISI IT:
Company
GAS -EA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GR17ASE TRAP
SOILS FEE
SEWER - SANITARY - STORM 1A. 200FT.
ENERGY Fli
(Thissection neermmt be eomphsd Hine permit B(.,are hundred doRan(SIM)
ter less.)
WATER HEATER WNENT(ELECTR
at,
I cenify in., in the performance of the work for which this permit is issued, l shell
not employ any Person in any manner, an as to become subject to the Wmkeri
PAID
Compensation Lawsof Califoram. Date
Applicant
WATER SYSTEM/BEATINGas
R.ciptN
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Cale, you must
NEW RESIDENTIALPI.MB. SQ, PT.
TOTAL:
forthwith comply with such provision or this Permit shall be deertsd revoked.
B LDIN T .N
CONSTRUCTION LENDING AGENCY
S17ISMIC FE -
1 hereby affirm that them is a concoction lending agency for the performance of
the work /orwhat, this permit is anted (Sec. 30X97, Civ. CJ
Lenders Nome
TOTAL:
d.ECTRIC/F.A a`
dW
Leaders Address
QTY. MECHANICAL PERMIT FEfi
PLUMB( FEE
I cenify that I have read this application and state that the above information is
comae,. I agree as comply with all city Infirmary ordinances and statelaws slating to
PERMIT ISSUANCE
MECHA (CAL FEF.
building construction, and hereby smhoriss representatives obthiscity terrorist upon the
ov
abe-merioned property for inspection purposes.
ALTER OR ADD TO MUCH.LID
CONS UCTIONTAX -
I
(We) agree to save, indemnify and keep humdess the City of Catarina against
Iiabilifes,j.dgmems, emasind expense which may in any way accsveigainst said City
AIR HANDLING ONI'1'(1'010,00I1 CFM)
in ce (the cortin ofthispmnit.
AIR HANDLING UNIT (OVER IBM0 CFM)
EXI IAUST HOOD WIMUCT)
PAID
Sir.ittimisIB App icuMCon ssual me
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dom Receipt
Willow applicant or furore building occupant store or handle h tmrdoas mmerial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health=it Safety
HEATING UNIT (OVER 100.000 BT U)
TOA(
Codd, Senl El 25532m)?❑ N
VENTILATION FAN (SINGLE RISID)
am.)future
WIII air
equipmentQuality
by
BOILIIR- COMPDHPOR 100.00013TU)
ISS NCE DATE
P p O
BOILER - COMP OVER 100,000 BTU)
conic the ay
hamrJous air contaminants as defined by the Day Area Air Quality Management
defined Manaes gement
lJistrid7 �
Ism !=!
❑Yes 11 No
I
1 Love read m
the hroodu s merials requirements under Chapter 6.95 of the
NOV 1`-pppp 19X((��
%3
NEW RESIDENTIAL MUCH. SQ. FT.
California Health & Safety Cade. Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have o tenant, that it is my responsibility to notify the
/� ^I I Y Ue LUT CYI1
accupam of the rapdremera which must he met Prior to macrame of u Cerci ficme of
Occupancy.
ISSUED BY:
Owner, nr aathorieed ager Date
OFFICE