25094fxanus ICANT TO MI IL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
z
2
7
] Q
3z
) Q
]U
- CLl
,c
. to
J z
CITY OF CUPERTINO PLUMBING - MECHANICAL
' BUILDING DIVISION' APP LICATIONIPERMIT
'.•BUILDING PNOJF.CI'IIJENTIFICATION
PERMIT NO. 25094
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBRUFAL DAII:
ss���,/�y /., �� ,rL �.s /��
Y' d JMIWp,•� 4e` �b.UNITa/`i4X. AEi/LGTa
s 1
WN[RS NAME: L� PHONE :
CO� M AW�. �� � ` LI�,5O
NIC
COMH(ILp
RCNI '/ENGINEER: LIC NO:
ADURf Jb a Y ��'A. S �l o6
NTACT: PHONE:
Q11•�. Lh' si' ELECTRIC PERMIT fhart gd f')''^l;
_
d'`a'BUILDING PERMIT INFO*:: .. •".
IJLUG ELECT PLUMB MTCH
PERMIT ISSUANCE
❑ ❑
LICENSED CONTRACTORS DECLARATION
1 herebyoflvm Nal l am licensed under pwvisionsor Chaper9(mmmencing wish
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section 7"Iaf Division 3ofihe Bminesand Professions CWe.and myboarse is in
fiolficonearadeffort.
Brecon Classlsss Lic.g
PANELS
N'T02(NIAMPS
g/p at IITO1w
Dae Commcha
ARCHITECTS DECLARATION
I understand my ].,.hall be used u public records.
201- 1010 AMPS
SQ. FT. FLOOR AREA
5/SV' FT.
OVER HIM AMPS
SIGNS ELECTRICAL
Llensed ProfeuiaaW
OWNER.BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt frau the Contractors License Law for line
following reason. (Saxon 7031.5, Business and Profeuinsa Code: My city m county
TEMP. METER OR POLE MST.
which requie, a permit to construct, Who. improve, demolish, or repair any structure
prom its issmnce, also requires the applicant for such perm tofale asigned statement
POWER DEVICES
" he is licensed pursuantmi the provisiomaf Ne Conuemora License Law (Chapter
mth.t he is exempt therefrom and the basis for the alleged! ascription. Any viol.ion of
9(c.ormaing with Section 7").f Division 3 ofthe Eastman, and Professions Code) ati
penalty of
Seen.. 7031.5 by any spplicsamfor spemmaubjem. Ne app)i.1to a civil pen
SWIMMING POOL ELECTRIC
VALUAT{QN d
D /0 U I
0
OUTLETS-SWITCHES-FlXTURES
t more than five hundred dollars($5110).
[3I.noi oftheproperry,mmyemploy withwagmu6cirsolecompcnsaaon,
NEW RFSIDENTIAL ELECIR —SQ.FT.
STORIES
TYPE CONSTRUCTION
willed.B w.LWtbestrucuvei,notine Morofferedfm Wc(Sm.7044,Businm
and Professions Cade: The Contractor's License Taw does not apply to an owner of
property whobuildamimpraves Nerenn, and whodoea suchwmk himself., dr ... hhis
own employeeaprmided Nat wchimprovcmcnuarc notinenddorofferedfor We. If.
OCC.
RES. UNITS
TOTAL:
however, Ne build ng.r improvem rat is wld within me yw ofcompletion, thcowner-
builder will have the horde. of proving that he did not build m improve for pmpvc of
We.).
I,uowner oeNe
❑ property. unexclmivclycantrwting with licenssd ronvmwn to
commet the project (Sec. 7044, Bmunms end Professions Code:) The Contractor's
1lcenuLwdoatmt apply man ownero(property whobuilds or improvathertan,and
FLOOD ZONE
APN
4 •v+�,e..;xw.manaa:xs.nss.n. T:i„,
try 'tPLUMBING PERIvirr "Fs EA
;i• ,i ;asrl-yerr
PERMIT ISSUANCE
wroconuacu farwcb projects with. contruunds) licensed pusvant .,he Comnmol.
Li. Lose.
ALTE0.-DRAIN&VEIN-WATER (EA)
iy ','w•�+`_FEE SUMMARY
a-. anq�.
js�tai0gt,; {yx
❑ 1 am exmtpt under Sa. . B & P C for this recta,
BACK FLOW PROTECT. DEVICE
OUTSID
SANITARY Y N
RECEIPT
Dae
DRAINS - FLOORROOF,
, ,,
�0Q
WORKMAN COMPENSATION DECLARATION
Q' IhcrebY aRmn Natlhaveacenifiue ofmmentmsev in:are.m.cmifiuu.r
W.rkao'Compmsation Insurance ora eenifid copy therec((Sec. 3800, Lab C.) which
coven all employees uadc, this pemdL
Pais, g
SCHOOLTAX Y N
RECEIPfN
FlXTURFS.PER TRAP
PARK FEE Y N
RECEIP `#
GAS - p. SYSTEM -I INCA OUTLETS
BUILDING DIVISION FEES
Company ❑ Ce Ceniftedcopyisherehyfumishd.
❑ Certified copy is filed with the city impauon division.
GAS-EA.SYSTEM-OVFR4 - i
AN
`':4
GREASFJINDUSTRL WASTE I R FP -TOR') \' m
RADI
' CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP CAD I)'�
IL MEJ—.j _PCOMPENSATION
INSURANCE
SEWER- SANITARY -STORM EA. 2 -
ER F
(Deis scman need not be completedifthc permit is fortune hundred dollan(SIM)
m few.)
I certify that in the performance ofthe work for which this permit is issued,I shall
WATER HEATER WNEN'I/EL _
1
tat employ any person in any an. w u to become x.b*, I. the Workers
Compensation laws of California. Date
_ Js
Dam Rcttipt4
WATERSYSfEWOUITING L--
Applicant
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
NOTICE TO APPLICANT: IL afar making this Ccnifc.,• of Exemption, you should
become subject to Ne Worker's Compensetim provisions of the labor Code, you must
foMwith comply with such provisions or this permit ahall be deemed invoked.
BUILDING FEE BO
SEISMIC FEF. r -�
CONSTRUCTION LENDING AGENCY
1 hereby afford mat than, is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Name
ax Fig• .u. '. s:rrywTy'-rw,ar. 1,v e�'i
Q7rvY 1f7a. MECHANICAL PERMITiq'vzy FEE r,�
[b," '•cede"vatT>• ..
PLUMBING FEE
Larder's Address
1 cerin Nat I have tend this application and sue but the above mfomeliam as
correct. l agree to comply with all city and county ordinances and sea laws relating to
•
PERMIT ISSUANCE
MECHANICALME
building construction, and heehy authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
ALTER OR ADD TO MECIL
CONSTRUCTION TAX
(We).9. t. save, indemnify and kap hamde.s me City of Cupertino against
Iiebilities,judgmmu.cmus and expenses which may in mywaymttmeagaimtwid City
AIR HANDLING UNIT LTO I0.000 CFM)
in coneyuence of the'malm, of this permit.
AIR HANDLING UNIT (OVER 10,0047) CFM)
EXHAUST HOOD ONMUC)
PAID
Simumre of ApplicmtlConracmf Date
❑EATING UNIT (TO 1M.00,I BTUI
HAZARDOUS MATERIALS DISCLOSURE
Will the applu:ma or future building cwcupmt same tar handle hazardous mmcriul
az defined by the Cuperimr Municipal Code, Chapter 9.12, and the Health and Safety
Dam N...... a
HEA TING UNIT (OVER 1010,000 BTU)
' J
TOTAL: , �V
VENTILATION FAN (SINGLE RESID)
Code, Section 3532(x).
❑ Y., a
Will theyglinmarfdurebuildin'occupmt ussequipmemwrdeviceswhich emit
BOILER- COMP CHIP OR 1(0,00) BTU)
ISSUA C ATL
FJ A I U
BOILER - COMP (OVER 100,000 BTU)
Installation. W entsmivnts as defined by the Bey Area Air Quality Management
BodicR v
13 Y. o
-
MAY 19 1993
NEW RESIDENTIAL MBCH. SQ. FT.
1 have read Ne hasamous materials requirements under Chapter 6.95 of the
GlifwniaHWN&Safery Code,Satinsa 25505.25533 and 23534. Imdeaund that
fifth Wildingdm no curtentiy Mvaaemnt,dat it is myrexponYDilfy on e
``1l y OF k Lr Lfl l ll4V
m h the t Prim m issuance v of
'bemen
Qo Pa
�
J
ISSUED BY, " L�
Owner euNari a'
TOTAL:
UF -Mot