25406'Ir
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL-POINT PEN ONLY
CITY OFCUPERTINO -•
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
BUILDING PROJECT IDENTH'KATION-•'
PERMIT NO.
25406 C ^ O 6
L J L'F v
BUILDING ADDRESS.
SANITARY NO.
APPLICATION SUBMITTAL DATE
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��CT��/E=NAGINEER:.
CONTItA1C1'OR'SNAMEE:�% rV LIC NO:
NIC
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COM'NOL
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SALa CN�1 NO:
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TY L,ELECTRIC PERMIT .
•..{e.' BUILDING PERMIT INFO- --.'
BLDG EPLUMB MECH1�
V PERMIT ISSUANCE O�
fL�)if. '-r��J El ❑
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed underprovisiomof Chup9
¢r(commencing with
Section 1000).( Division 3 of the Business and Pmfessiom Ctd,,mul my liana, is in
full fora and effect.
License Class a
APPLIANCES - RESIDENTIALyv
�L
PANELS
UP TO 200 AMPS,.
JOB DESCRIPTION
nis k—T�
m
2 - ❑x%) MI'S
eCo
Date
ARCHITECTS TS DECLARATION
I undenund my plans shall be used m public records.
SQ. FT. FLOOR ARBA
8/SQ. FT.
O 1 A
N CTRICAL
Licensed Professional/
OWNER-BUKDER DECLARATION
ECIALCIRCUIT/MISC ')
ft
I hereby aRrn that 1 em exempt from the Contractor', License law for the
SLE
following... (Section 7031.5. Business and Pmfewians Code: Any city m cmmy
TEM. METER O N
which requires a pemut to construct. Wer. improve, demolish, or repair any swcturt
prior to its iumancaalso requims Neapplicant for such permit m ftl... ignedsu anent
POWER DEVICIIS'.,
that he is licensed punuam ton the povisiom of Ne Camosemrs License law (Chapter
9(commencing with Section ]WO)of Division Sof Ne Business and Professions Cade)
or mu he is exempt therefrom and tha basis for the alleged exemption. Anyviolmionof'e
Section 7031.5 by anyapplicautfor a permit subjects me ep,barmnna civil penalty of
SWIMMING P06f ELECTRIC
VALUATION
iy- ,1 spy
NsU[ v r�
V OUTLETS - SWITCHES - FIXTURES t SD
not than o
❑ t,uowaftheMpny.mmympl oewim wgnemeirsnlempnsetion,
NEWRESIDENTIALELECTR _SQ.Fr,
STORIk
TYECONSTRUCDON
will Lndedoroffendforsale(Sec. toW, Business
he Contisriots
and Professions Code: The Camnctors License law dares not apply to or owner of
prthework. Code:
propenywhobuildsm malso vesmani eadwhodoes s ichwork hirmelforthrougb his
cmmucarenot intendedmoffared for
osisemployees,provorithatsueherat
OCC. GROUP
RBS. UNITS
TOTAL:
is owner.
of completion, Neowner
however.the illhav the burden of pmemrisaat he did
builder will have the burden of proving Net he diJ rwt build m improve for purpose of
ijr• . PuGI INGRPFRh:ITI�`s v" I FFE _
sale.).
❑ I,mownerofOepmpeny.=m clusivelyco wwtingwi Licensed conrnctonto
MOOD ZONE
APN
construct the pmjat (Sec. 1044, Busmas and Professions Code:) The Contractor's
Ilse Uwdwnot pplytomawrmrofpropmywhobuilds«bnpmvntheremn,end
g
PERMIT ISSUANCE
who cmtrecu f« such projau wi th a contractor(s) l icenud pursuant no the Contractor s
Li«rase law. -
ALTER -DRAW EiiT'-WATER --' �d ; V
:- ' i • _ —
„ FEE SUMMARYy„a�,}y'-.-a;.4^`.:.,!.s'
- s 7,:X;�
❑ 1 nn exempt underSec. , B & P C for oris reason
BASIDE
CK FLOW P : DBVIiE
UTY FEES
pNITARYa N
WORKMAN COMPENSATION DECLARATION
DRAINS -FLOOR, OO ARFA,COND.,
H0,gLTAX YECEIPTa N
I beats affirm that l have a certificate of consent to self4roure, or a certificate ofFl
W«ken•CnrWerrvrim lmunn««aartifiM copy tlterm ((Sa.3800,1ab C.)which
cuvcnall employee's under this permit.
Policy
R[CEIPTM
CTLtRES -P�.�A�
-�LE Y N
RECEIPT♦
GAS - EA. _-I INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE •� �+
lgi-C..]
❑ Cemifiedc.,ninebyfumishel.2.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cerifiedcopy is filed with me city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION MSURANCE
SEWER - SANITARY - STORM FA. 20017,
ENERGY FEE
(This section need not be completed if Ne permit is forone hundred dollars(SIM)
«tars.)
Icertify door in the per(ormance of the work for which,hia permit is issued, label]
WATER HEATER W/VENf/ELECTR
��-�o�1R�L9
not employ any person in any manner so . to become subject to Ne Workers'
PAID •]
WATER SYSTC•M/BGT/NG
Compemationlawsof California. Date
Dae Receipts
Applicant
NOTICE TO APPLICANT:If, afar making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL: Di—
become
Fsubject to the Worker's Compenmtion provisions of the Labor Code, you must
rnMwith comply with such provisions or this permit shall be deemrd revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE la
I hereby afemr met mere is n Construction lending agency for the performarm of
the work for which this pemdt is issued (Sec. 3W7. Ci, CI
TOTAL:
ELECTRIC FEE j
w
Leader's Name
Iandds Address
QTY:�;;i+r':_i;, MECFIAN A P wNUT�;” FEE"Vie'
4 ::
PLUMBING RE
I certify that I have rutl this application end sate met me above informnion is
<correctlegrecmcnmply with ell city end county nrdinanasund sate laws relining to
PERMIT ISSUANCE-
MECHANICAL FEF.
building consructim, and herthy eutharire reprncnmtives of this tip m am,, upon he
rebore -mentioned property for impaction purao,,
ALTER OR ADD TO MECH.
CONSTRUCTION I'AX
(We) agree in save, indemnify and keep harmless the Cite of Cupertino against
Iimbilitiesjudgmems. costs and expenses which may in any wayacamc against saidCity
AIR HANDLING UNIT (TO 10.01M CFA)
in consequence of the graining of Nis permit.
AIR I IARULING UNIT (OVER I0.000 CFhH
SlgnawreMAppb<unJCanunnor Dart
EXHAUST I{OODIW/DUCT)
PAID^�
HAZARDOUS \IATERlALS DISCLOSURE
Dat, Raceipta
HEATING UNIT 1(10.0(1) BTU)
HEATING UNIT (OVER 100,000 BTU)
_
TOTA
Will the applicant or future budding occupant stare or h:mdlc haxurdms material
as def mrd by Ne Cupenuo Mum pal Cade, Chapter 9.12, and me Boom and Safety
COAe, Section 25532(e)1
❑ Ya
'
VENDLATION FAN (SINGLE RESIT)
ISSUANCE DATE
Wutheailicentorfutumbuil& acctsmtuae
PP g v ega�pmentnraerieerwnian,mir
s air commutations a defined by the Bay Ara Air Quality Management
IdOw
BOILER- COMP QHP OR IMMID BTU)
P A I D
BOILER -COW (OVER 100,000 Bit)
❑Yes No
NEW RESIDENDAL MECH. SQ. FT.
I have read the Retentions materials requirements under Chapter 6.95 a the
AUG - 9 1993
Califomi s Health It Safety Cade, Sections 25505, 25533 and 25534. 1 understand than
if the building don and currently have a twat. that it u my responsibility to notify the
oats " of the rtquiremen 'cit mart be rnet Fri« u issuance tot a Certifisve of
fl -i -q
gs
CI1 T l ul'CITd Illu
J ft�� l�uc .
ISSUED BY' '
'O --ora enc - Data
TOTAL:
OFFICE