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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO IIm:.1bli-e.nC'I A.
BUILDING DIVISION APPLICATION/PERMIT I'LUMBINO-MIIDENTIFIC
- BUILUINC PROJECT IIIENTIFII'ATION
PERMrrNO 1r��
2 5 O Z 4
BUILDING ADDRESS
UNITX LOT#
SANITARY NO.
APPLICATION SUBMrrIT�ALDA'IT:
Lt.- S
O RS NAM F� PHONE:
//
CO r '$ NAQMf:: LIC
A O/ -GLI C O:
N/C
❑
CONTROL#
AH�.rHI :(T'IENGI�'ER:�
Sc t.l
I.ICNO�OS�h
a
CONTACT':' PHONE:
QTY. ELECTRIC PERMIT PER
BUILDING PERMIT INFO
BLDG) PLUMB PLUMB H
PERMITISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that l am licensed underprovisionsof Chaper9(commencingwith
Section ]WO)of Division 3 o the Business and Professions Cudq�5iny license it on
fuR force and eB Ie,_ — I
License YS/Lic.#—�/�p
APPLIANCES - RESIDENTIAL
TOB DESCRIPTION
PANELS
UP T0300 AM15
Dae ContractorLJ=./aIZS/YC�_
201 - IINq AMPS±20
AHCIIITECP5 DECLARATION
1 understand my plans sh 11 be used as public records.
OVER 1000 AMPS
SQ. FI'. FLUOR AREA
4e.
7
$/SQ.ITI'.
SIGNS IiLF,CfITICAI.
Lmennw Profexamad
OWNER -BUILDER TION
SPECIAL CIRCUIT/MISC.
m the Cameroon'sLicense Law for the
from am
I hereby aRmt that I um exempt from the Crsamm,
/
TEMP. METER OR POLE. INST.
Ca
following taus, (Salton 7031.3, Business and Professions Code: Any city or county
which requires n permit In ei,that, imroves repair any re
soregms,hefor h Ivermnto fi signedstatement
POWER DEVICES
thathe ilicensedpursuant to the Provisions ofthe Co 's License Law (shaper
9(commencing with Seetion]p0)of Division Jofthe Business adProfessions Code)
or that he is exempttherefrom and the basis for thealleged exemption. Any violation of
Section L5 by any applicnmfnrnpennit subjects *a., to ecivil penalty of
SWIMMING POOL ELECTRIC
VALUATIONOO
C O Ow ���
ger/
.►
LETS-$WITGHFS-ITXTURES ft
not mort than five hundred dollars P$SWI.
❑ ,
`l
NEW RESIDENTIAL ELECTR _ SQ. FT.
STORIES
TYPIiCONSTNUCTION
willdo the work, and thesuumurcis not imendeduroffercd forsaleSoc. ]044. Business
and Professions Code: The Contractors License Law does not apply to an owner of
prnpeny who builds or improves thereon, and whodocs such work blmsell'or through his
empinyces,pxwLcdha suchimpowemeasac not inendedmofferedforsale.If,
OCC. GROAT'
RES. UNITS
A
Imweveq the buildingor improvement is sold within one yeerofcomplation, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY' PLUMBING PERMIT 'IeEc
sale.).
❑ I,mowncrofthepmo ay,amexclusivelyconvaetiagwithlicnm convactorsto
FLOOD ZONE
APN
construct the project (Sec. 70,14, Business and Professions Code:) The Contractors
License Law does not apply to anrwnerof property whobuildsorimprovesthereon.and
PERMIT ISSUANCE
whoconvamsfor such projects with a concer(s) licensed pursuant mlhe Convectors
License Law.
g1.T1iN- DRAIN &VGNT-WATER (EA)
FEE SUMMARY
❑ 1 um exempt under Sec. , U & P C for this rcnmo
gpCK FLOW PRO
I1T51 s EF
S ITA YN
RECEIPT#
Owner Dae
DRAINS -FLOOR, OOF;ARP,A.
PIXTlIRE3-PERT P
O
WORKMAN COMPENSATION DECLARATION
I herebyaffiWo that l have. cartinameof consent to self-iaxum. or a cenitleueof
' WOrkem'Campensation lnsurnceoru artifiw copy thereof lSec.38IX1, Lab C7 which
OOL AX Y
RECEIPT'#
1' FE YN
covert all em s d t.
Policy#
GAS EA. SYSTEM -I INCA LETS
RECEIPT#
BUILDING DIVISION FEES
t�
Gampmry1 h
GAS- EA. SY.'1'EM OV'R4(EA)
PLANCHECK FEE
❑ Cenifiwcopyisherebyfumished.
GREASMNDUSTR6 WASTE INTERCEPTOR
GRA DING ME
li✓Cenifiw copy is fled with the city inspectiondivision.
CERTIFTCA9'130F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS Hietv
SEWER - SANITARY - STORM HA. 200FT.
ENERGY FEE
(Thissection readout be campleed ifthe permit is forone hundred dullan($IW)
orlessJ
WATER HEATER W/VENT/ELECI'R
I certify that in the performance of the work for which this permit is issued. I shall
not employ any Perron in any manner so as to become subject to the Workers
PAID
WATER SYSTEMTREATINGUa
Compensation Lawn of California. Dae
Receipt#
Applicant
NOTICi;TOAPPLICAW:lf. Oermakingthis CeNficmeuf Exemplion,youshnald
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you must
forth, lth armply with such provisions or this permit shall be deemed rooked.
B 1 0 'EE
SEISMI FEE D
CONSTRUCUONLENDINGAGENCY
1 hercM1y uffirnt ihenherc is a consvuction lending agency far the performance of
the work for which this permit is issuw(Sce. 3097, Civ. C.)
Lenders Name
TOTAL:
ELECTRIC FEE.
Lander', Address
QTY. MECHANICAL PERMIT FEE
PLUMBING
I certify thin I have read this application and state that the alcove information is
treat. l agree to comply with all city and county ordinances and see laws reining to
PERMIT ISSUANCE
MECIIANICAI FEIi
building construction, and hereby callotis representatives of this cirymemer upon the
above-mentioned pmpeny fur inspection pm,mc,.
ACLLR OR ADI)TO MECH.
CONSTRU TAX
(We) ugbm nr save, indemnify it keep harmless the City of Cupertino against
liabilities,judgmencosh and expcnsex which may in any way accrue against said Of,
AIR HANDLING UNIT CFO I O.W CFM)
in cquen oft rn u hiss a�fn
_ —
I Yz
AIR HANDLING ONG (OVER 10,000 CFM)
ID
Signature of Applican tm m, ate
EXHAUST HOLD(W/DUCT)
I MATING UNIT (TO 100.000 B' I' U)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building accupum store or handle barnrdoas materiel
as defined by the Copeman Municipal Cade, Chapter 9.12, and the Health and Safety
HPATING UNIT (OVER IW,tJlIfI BTU)
V17WTLATION FAN (SINGLE RESID)
F
Code, Section 25532(e)1
El Yes !NYl/u
Will theapplicanmrfmurcbuildingoecupant useequipmenmrdeviaswhich em
BOILER - COMP (3HP OR 100,000 BTU)
ISSUUANNCIDQ,TEit I1 lVJ
bazardoua air contaminants t defined by 0n Bay Am. Air Quality Management
t Disvia7
BOILER -COMP (OVER 100,000 BTU)
❑ Yu No
n
R N J
'APR 2 91993 1993
NEW RESIDENTIAL MECH. SQ. Fr.
1 have mad the hazardous materials requirements maker Chapter 6.95 of the
Catifamia Health &Safety Code, e, Sections 23505.25533 25534. 1undrm
eand that
tl vet tenants it y responsibility to notify the
CII'y err fur
'#
ky Pic it
req Item tr hie t ust ben t prim n Issuance of a CeniOeuta of
ISSUED BY:
092 nothoriac i agent v 0 Dote
ARTA re
OFFICE