26206%PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
B141,11IN7-RLF.c 'FRrCAr
CITY OF CUPEAPPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISSIOIO NO N BUILDING, PROJECT IDEN'TIFICA
3UILDING ADDRESS:
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FEE SUMMARY
OUTSIDE FEES
SANITARY V N
RECE1FF'p
SCHOOL TAX Y N
RECEIPT' p
PARK FEE YN
RECEIP 4
BUILDING DIVISION FEES
PLANCHECK FEF.
GRADING PEI:
SOILS FEE
ENERGY FEE
PAID
Dam Reccipta
TOTAL:
BUILDING FEE
SEISMIC FEB
EC
ELTRIC 19iC
PLUMBING FEE
MECHANICAL FF
CONSTRUE ON'I'AX
PAID
Date Receipttl
TOTAL:
pd�
ISSUANCE DATE
P W C ®
MAR 29 1994
CITY Ur uu�TJ`Y/
ISSUED BY'.
0
ARCIII'ILCT/I' GINE:R: LIC NO:
A %S. 5)C.• �• ��(/,]
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CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
*J-7;1-7-1545
PERMIT ISSUANCE
LICENSE CONTRACTORS DECLARATION
APPLIANCES -RESIDENTIAL
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I hereby affirm than lam licensed nnderpmvisimruf CTapmr9(mmmeeringwith
Secirm 7") of Division J ofilm Business and Professions Cade, and my license ism
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Dam Contractor
UPTO200AMPS
201 -IOW AMPS
T -S DECLARATION
I undensmnd my plan, rball be used ns poblic reaads.
W
OVER IOAMPS
SIGNS ELECTRICAL
LicensedPmfeasianal
OWNER -BUILDER DECLARATION
I hereby affirm @m I am exempt from the Contractors License Law for the
following mason.(Section 7031.5. Business and Professions Code: Any city or county
which requires a Permit to construct, alter, improve, demolish, or repair any structure
poor to its issuance, also requires the applicant for such permiuo file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 with Section of Division 3 or the Business and Professions Code)
(that heir (commerical, wi )
or 7031.5 by yapplimandthe bmisfomhectsegWexempt to Any violation of
Seainn]W LSF 1 tfora tsub is thea Ic uoa civil ❑ f
ec ter app idol person lee pp i an pens y o
not more than five hundred dollars ($Sllt)'
❑ 1.mownerofNepropeny.ormyemployecswiNwagesadteirsolecompensation,
,w ill do the work, andthe swaure isnot intendedor offered forsale(Sec. 1044, Business
and I'mus,i I, Calc The Carrowlens License Law does not apply rat as owner or
SPECIAL CIRCUIT/MISC.
TIiMP.MEI'ER OR POLE INST.
POWER DU 'S
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FI%'NRES
NEW RESIDENTIAL ELECT -1 _SO'PT� 0U
DATE
propcny whobuiltlsor impmvcs thereon, and wM1odms such work himselfm hough his
own employees, provided that such improvements are not mounded or offered for sale. If.
TOTAL:
however, the building rat improvement is sold within one year ofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT F.E
sale.).
❑ Lmowour of Oepropeny,umexclusively contracting with license) nmtractorsm
consumer the project (Sc. 7044. Business and Professions Codc:) The Connacmr's
License Lawdocsnot apply to an owner ofpropeny who builds or impmvesthereon,and
PERMIT ISSUANCE
wbocontructs for such lanjeeb with scnntmdngs) licensed pumunt to the Contractor's
License Law.
ALTER - DRAIN &VENT- WATER (EA,)
❑ lam exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
Owner Date
DRAINS- FLOOR, RODE, AREA, COND.
WORKMAN COMPENSATION DECLARATION
T
FIXTURES - PER RAP
❑ Iherehy affirm thmlbaveucenifica¢of umsenuoself-insure, ora cenifemc of
Workers Compensation lmsurance rracenifid copy Hereof (Sec. 38W, Lab C.) which
GAS - EA. SYSTEM -I INC. 4 OUTLETS
covers all employees under this permit.
d
Pnluy N
Crsmyany
�.{ Certified copy is hereby famished.
GAS - Est. SYSTEM -OVER 4 (EA)
GREASH/INDUS'I'RL WASTE INTERCEPTOR
❑ Certified copy is fled with the city inspection division.
CER1119CATEOFE%EMPTION FROM WORKERS
GREASETRAP
COMPENSATION INSURANCE
SEWER -SANITARY - STORM E- .2WIT.
(This sectimmand not becumpletetl ifthe permit is forone hundred dollars ($1100)
ter IcsIJ
WATER IIEATER W/VIiM �13LBC1'R
certify the for whichthisiubject to issued,Workers
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so act
not employ any serum in any manner so m m become subject m the Workers
any person in my ma n
Compensation Laws of CaliLtmia. Date
Appfirmd
NOTICETOAPPLFCANT:If. otter making Ibis CcniEwm of Ea<mption, you should
WATER SYSTEM?RLATING
NEWRESFDENTIALPI-MB. SQ. FT.
F pl
become suhjca to the Worker's Compensation provisions of the labor Cale, you most
forthwith comply with such provisinnsnr this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
1 hereby affirthatthere is a construction lending agency for the Performance or
m
the work for which this permit is issued (Sec. 3W]. Civ, C.)
Lenders Name
TOTAL:
Q'I'Y. MECHANICAL PERMIT FEE
Lenders Address
1 ttnify that I have read this application and sure that the above information is
correct. lagree'.comply with all cityaod... my.ohnances and state laws relating to
building construction, and hereby authorize repoesenninscso'this city'. corer upon the
most-asurnned progeny for inspection purposes.
(We) agree to save, indcmndy and keep harmless the City of Cupertino against
Iiabilities,judgmcros,msu unit penuswhich may in any way accme against said City
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 10,000 CPM)
inc ce of the grant fruits it.
i,
AIR HANDLING UNIT (OVER IO,IX) CFM)
EXHAUST HOOD(WNUCF]
Signal.. of ApplicanVCm ter Date
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNTT(TO Itb,OUO B' I' U)
Will the applicant or furore building racupantsmre an handle hvardous mamdat
,,defined by the Cupetino Municipal Cade, Chapter 9,12, and the Health uad Safety
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE R1SID)
EN
Cade, Section 25532(aC F�''
❑ Yes fyvo
BOILER- COMP(JHP OR IW.SX) BTU)
Will the applicant orffutuum buildingoecupaut useequipmenmrdevices whichemit
Invasions air committal as defined by the Bay Area Air Quarry Management
BOILER - COMP (OVER 100,000 BTU)
v Disvicl? ���ttt'''
El yet 2y No
NEW RESIDENTIAL MECIL SQ. FT.
I have read the hazardous materials re ulreems under Chapter 695 ria the
California Health & Safety Crude, Sections 25505, 2553] and 25534. I understand that
ifri build's does sol cure ml have'tenant. that it is my responsibility m notify the
ccupan t t yurane x hie I Ise mm prior m issuunfe of aF mificam of
Occupan �� (� e
r'
V4�thorimOwner
aim
Owner dagenl bate
TOTAL:
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FEE SUMMARY
OUTSIDE FEES
SANITARY V N
RECE1FF'p
SCHOOL TAX Y N
RECEIPT' p
PARK FEE YN
RECEIP 4
BUILDING DIVISION FEES
PLANCHECK FEF.
GRADING PEI:
SOILS FEE
ENERGY FEE
PAID
Dam Reccipta
TOTAL:
BUILDING FEE
SEISMIC FEB
EC
ELTRIC 19iC
PLUMBING FEE
MECHANICAL FF
CONSTRUE ON'I'AX
PAID
Date Receipttl
TOTAL:
pd�
ISSUANCE DATE
P W C ®
MAR 29 1994
CITY Ur uu�TJ`Y/
ISSUED BY'.
0