25207 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-ELoCTRICALPERMIT NO. 25207
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BUILDING DIVISION , APPLICATION/PERMIT PLUMBING-MECHANICAL [,5 Z O 1
7
BUILDING PROTECT IDENTIFICATION
PU11
ADDRESS C - - SANITARY NO. APPLICATIOIN/SSUBMGTAL DATE
- O r a7� S Y V« S C UNIT# _ LOT# r �S
OWNERS E: PHONE: CONTRACTOR'S p1 AME LIC NO: N/C C-OM1fR—OL#
ARCH : INEER: LIC NO: ADDRESS: Ll/ -
41 S4. 'Tr 1�'✓Sri 17 7
CONTACT PHONE /(j r#[ O
EL MIC PERMIT FEE J BUILDING PERMIT INFO
E"" BL LF.Cf PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRA(7fOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz 1 hembyaffrm that l in.licensWunder pmvisionsaf Chapmr9(omennacingwith JOBDESCRIPTION
IN00C Section9W0)ofDivision3oftheBusinessandProfessionsCode,saidmylicenseisin PANES Pd
ee V U full forte and effect.
NC Zatyy � qO�
/Licen
DamsSlass7� Lic.p R
TO 200 AMPS
Commit.,
20L1000 AMPS
z0 zARCHITECT'S DECLARATION OVER 1000 AMPS SQ.1.7 Qpg ARHJ ISISQ.PI'.
O z q 1 understand my plans shall be used as public records.
F tn7m SIGNS ELECTRICAL I G �
4 '� Licensed Professional rr�� p
woa6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I� n Imo+ II IIER
ipyx(,�0.F I hereby.f lon that I non exempt from the Contractor's License Law prime L*,J II V'
n+31s.w following reamn.(Section 701.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires s pcmdt to conswct,alcor.improve,demolish,or repair any structure
�WYN prior to its issuance,also requires the applicant for such pennino file asigned statement POWER DEVICES DAT
MIK<O that he is licensed personal m the Provisions oflhe Contrac.,'a License Law(Chapter
n XQ�- 9(commcncing with Seedan70813).(Division 3 ifthe Business and Professions Code) SWIMMING POOL ELECTWC VALUATION
W,_y or that he is exempuherefromand the basis far the alleged exemgims Any violation of OUTLETS-SWITCHES-FIXTURES
�zY Sectio 1703 L5 by any applicant for u permitmbjerts dis..,licom to at WITCHES pcnelty of
uC < not more Bron five hundred dellers($500).
uIIFp ❑ Lesownerofthepropcny,(rmyemplryaswiN wagesastheiraolecrmpensauon, NEW RESIDENTIALELECTR —SQ.I STORIES TYPECONSTRUCIION
will Jo the work,and the structure isnot intended orrffered forsale(Sec.9(44,Business
and Pmfeasiers Code:The Contractor's License Law does not apply to an owner of
pmpenywhobuildsrrimpmvesthereon,andwhodas such woe himselfordemugh his
employees,provideA tem such improvnnenta are not intended oroffcreA fnreaie.IL OCC.GROUP RES.UNITS
howeveq the building or improvement is sold within ane ycarofcn oplatinn,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asOwneruflbepropeny,amexclusivelycontractingwiNlicensedcomraaorsto QTY; -,a PLUMBING PERMIT PEE FLO ZONE APN
conswct the project(Sec.7(A4,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does not apply loan owner M property who bui Ids or i mpmves thereon,and
whorommets forsuch projects with u contmetorod licensed parnmettothe Contractors ALTER (EA)License Law. FEE SUMMARY
❑ 1 tan exempt undo Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDETEM
SANITARY Y_N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT p
TIRATION SCHOOL TAX Y
• cover WORKMAN COMPENSATION DECLARATION
at
❑ Thereby affirm thntlharcecenificam(fcrnsem In Self-i.......ccrtificeoB RECEIPT
W.decnt Compensatm
ion lnsunce certified
or a copy thereof(Sce.3800,Luh C.)which FlXTURFS-PF.R TRAP PARK FEE. Y_N
s all employee's under this permit. GAS-FA.SYSTEM-[INC 40UTLE'TS RECEIPT#
Policy# BUILDING DIVISION FEES
Comp GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
Certified copy is hereby famished.
eIJ Camfted copy is filed with Ne city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI7 TRAP SOILS PEE
COMPENSATION INSURANCE
(Phis section need not be completed ifthe Permit is Borrel hundred dollen(51(0) SEWER-SANITARY-STORM M.200FT. ENERGY FEE
or less.)
I certify that in the perfnrrrwnce ofthe work for which this permit is issued,)shall WATER HEATER W/VENT/ELECTIt
not employ any person in any manner so u t(become subject to the Workers' PAID
Compcnsrtion Lawsrf Califomia. Data WATER SYSTEM/TREATING Date Rc ' tp
C z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLNIB. SQ.FT. .AL:
F' V) become subject m the Workers Compensation proviumis of the Inbar Code,you must
fordwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
(] CONSTRUCTIONLENDINGAGFNCY SEISMIC FEE
z I hereby affirm that is a construction lending agency for the performance of TOTAL: CLR IC '
(� O the work Na which this permit is issued(Sec.7(9T.Civ.CJ
Carrier's der'c Name PLT ING FEE
O F Lenders Addrtas QTY. - - MECIIANICAL PERMIT FET;
V I angry(tot I have,with this application and
and estate test the above information is
Y' a correct,constraxnmlidheeyauthaaid cuumyrnativncesand sale laws r upon gm PERMIT ISSUANCE %GHA. CAL PEI?
UUj movingconswdiroert herebyaection p,pose.uBvcsrf thiscity to enter upon the
V ahov(We)igme,to
inspection and purposes. ALTER OR ADD'fOMECH. CONSTRUCTION AX
(We)agree n save,Indemnify and keep hartnloes the City of Cupertino against
liabilities,judgmcnss.crxnnnd expenses whiMm eny wayaccrue agvnn said City AIR HANDLING UNIT('1'O 10,000 CFM)
in cn ming of this
AIR HANDLING UNIT(OVER 10,(I00 CPM)
gnaturc I'Applicant/Co muctar Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('I'0100,0X0 BTU) Dam Receipt#
Will the applicant or future building occupant stem or handle htakedom material HEATING UNIT(OVER IM."B'IU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(a)'.
❑Yes VENTILATION PAN(SINGLE RESID)
W i IHhe applicant or I'umre building occupant use equipment or Devices which emit
POILER-COMP(311P OR 100,0110 BT U) ISS NC.DATE
Imperial,air c.mean ne I defined by the Bay Arca Ail Quality Management
�District? BOILER-COMP(OVER 11X1,000 BTU)
❑Yes NEW RESIDENTIAL MECH. SQ.Ff. / 4 10
I have read the haaardous materials requirements under Chapter 6.95 of the V
California Health as Safety Code,Sections 255(5,25533 and 25534. 1 understatement 'v
if the bidding Jens not currently have.tenant,t t is my responsibility to notify the /s Q/�
cupant of the nu which t b rior to issuance Of a Certificate of City`r 9 3
o«npan ���j�'��/l-93
Owner T/atmoomd agent Date TOTAL: ISSUED BY: �y
G 3ai� S RCA) ,
LOVE
JUWZ 11993
D
BLDG. INSPECTION DEPARTMEM
CITY OE CUPERTINQ
41- 44
,v
U/) - A 4- 4
J
APPROVED
Ao"AI766 WITH THE CITY OF
OFMINO CODS AND ORDINANCES
ORL,_ L
-
fifil§ sbt
of end�E s ecihcatiorns iIM
I3@ kegt on the Job at all times and it is uo
4— 7 i --------low. 16OUl to make any changes or alterations
dfl Seme without written permission f
the building Dept., City of Cupertino. rare
The stamping of this plan and specifications
SHALL N0T be held to permit or to be an
approval of the violation of any provisions
Of any City Ordinance or State Law,
o�
P�
OFFICE COSY
I/T r / 47('A /p
Z0'd 300-1 OIUDE 13 031ti0IUC W06J £9L0ZSZ000 01 M00 £6, SZ Nnr