25519APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - Bat I'DIN 111 PCTttics
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT' IDLNDFICAT'TON
PHRMIT NO.
25519
` n
BUILDING ADDRESS:��� � /'— // U ITK LOTk
�/T/gam 4,//_� /—/'`�.'O'iJQ`�
SANITARY NO.
APPLICATION SUBMIT] At. DATE:
/ l✓
OW SNAME: a /(SPI E:
IY/f
CON'TRACTOR'S NAME: LIC NO:
N/C
CONIROLp
fARCIIITT C-T/ENGI LIC NO.
ADDRESS:
CO CT: - PHONE:
`��--Te .✓� //
QTY. ELECTRIC PERMIT FEE
I BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 700H.1' Division Sof the Bminessand Professions Code, and my license is in
fallaAeffe.
License
License nu ClClass dLic.N
Dam Contractor
'APPLIANCES - RESIDENTIAL
10B DESCRIPTION
PANELS
UP 70200 AMPS
201 - I" AMPS
ARCHITECTS DECLARATION
1undofinaxand my plans shall boused npublic records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
LED I M V�
t --A p II ern few
'IIVp 1 1S+��
O
$/SQ. Fit.
_ I i
SIGNS ELECTRICAL
"
Licensed Profeaxional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contmdoh Licenu Law for the
Cade: Any city m county
followingreason. (Semon 7031.5, Business and Pm, demolish,
prior inquiresapermit to consumer, thealcor, improve, demolish, orrepair any structure
no slicensed pursuant
the Copermluo filessigned dominant hapter
that heto the
thin is cnw th Sectio m the) of Division
n 3 of Convenor's Licenu law (shouter
mi(commencingdhisxmithoreiae T00d the basisorumf the edBusiness
the permit um iumpnma. An violation
dexcmant to Anyyl Penity of
Sectio 7031.5 by the
Section 7031.5 by any died dont lin $ permit subjecu the applicant m a civil Penalty of
nm mum than fivehundreddollars yemp. -
❑ I,u%ownernfMepropeny,mmyemployceswithwegesauheirsulecnmpensution,
will dmhe work, and the swcture lana imended m offered ferrule (See.7M, Business
and Professions Cale: The Contractor's License Low does not apply to an owner of
pmpcny wbobuildamarpoweather. am end whodoessuchwork himan fmilromghhi%
rocoemployces, provided that such improvements scream iemndedoreffere. forsale. If,
however, Ne building or improvement is sold within one car of completion, themener-
builder will have the burden of proving that he did not build or improve fur purpose of
sale.).
hde:)'Mensed Cminctomm
❑ Las he project (Sev.70 nm Resume iv and Professions Coatmcmnd
Licensemistre d the project (Sec. otWq Bmineaa and Professions or improves
Lconae Law loos not apply ct an nh acrom propcaY who beddaorimpto me thereon, and
wicens,ansfor such projeaswithacontmcmrts)licensed pursuant to Convectors
License Law.
❑ 1 am exempt under Sa. , B & P C for this reason
SPECIAL CIRCUIT/MISC. - a i1 n
a C� 0 J
TIiMP. M61RR OR POLE INST.
(.TLE
POWER DEVICES tG
SWIMMING POOL ELECTRIC
VALETA
� (h
V
OUTLETS - SWITCHES - FIXTURES.
NEW RESIDENTIALELECIA _SQ. FT.
$T'ORIR_S
'IYPIi CONSTRUCTION
OCC. GROUP
FLOOD ZONE
RES. UNITS
APN
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATERER
GEA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
01'1 SIDE FEE:.
SANITARY YN
RT:CEIPTN
Own" Date
DRAINS- Fl.00RROfIP,AREA, COND.
,
WM
WORKMAN COMEATTON DECIARATION
❑ (hereby off tharlhave acenifica¢afconunno ulf-insure, ore eenificete of
Workets'Compencelan Insurance or acertifed copy thereof (Sec. 3800, Lab C.) which
covers all employee's underthis permitGAS-1?A.SYSTRM-I
Policy M
SCHOOLTAX Y N
RF.CEIPTp
FIXTURES - PER TRAP
PARK FEE Y N
- RECEIPTp
INC. 40U11ET5
BUILDING DIVISION FEES
Company
OAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ CcnifiW copy is filW nim the city inxpeednn division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
juk section need no, becomplenal if the permit is for one hundred dollars($100)
mless.)
I crafty that in the perfoonnme of the work forwhich this pmnit is issued, I shall
oat employ anyr�f a sonCnlin any manner w to hero a subje to a Workers'
rmpenmtio r
pliant
GREASMNDUSTRL WASf13 INTERCEPTOR
GRADING FEE
GREASE'IRAP
SOILS PER
SEWER -SANITARY- STORM EA. 200F1'.
ENERGY FEE
WATER HEATER W/VM'DULECI'R
PAID
Date RceciptB
WATER SYSTEMEATING
?B
CANifom'
NOTICE TO PPLT:f, oft"making is crit mama Exemption,yon should
become subje<uo the Workers Compensation Provisions of the Labor Cale, you ..at
mohwith comply with such provisions or this permit shill he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a convections lending agency for the perfor mnu of
the work for whichmis permit is issued (So.. 3097, Civ. C.)
Leader'. Name
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
BUILDING FEE
s
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Lenders Adirsm
QTY. MECIIANICAL PERMIT FETE
PLUMBING IEE
MECHANICAL THE
I comfy that I have mad this application and state that me above information is
coarct I agree to comply with all city and county ordinances and state laws reining or
building convection, and herebyautho ea represemadvea of this city menterupan the
ma.ve mentioned property for inspection purposes.
(We) agnx Interco. indemnify end keep hertalesa the City of Cupertino against
Iiuhilinp,jul menta, canto antl expenseswhich m:ry in anyway accrucegainst said City
v.of the gmmmg of this pcanit
Q�p
—,I
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ('fO IQtRgI CFM)
CONSTRUCTION TAX
AIR
AIR HANDLING UNIT (OVER 10,00f) CFM)
Si oars of Applicant/Common, -
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupam store or handle hevardous material
uadelinad by the Cupertino Municipal Code, Chnpmr 9.12, and the Heals and Safety
Code, Section 25512(a)?
EI Yea EI No
Will the applicnmor IircurehuilJingoccupnm use eynipmrmordeviceswhichemit
hazardous air contaminants m defined by the Bay Area Air Quality Management
Di%metl
❑ Yes ❑ No
1 have mad the hemrdous materials requi comms, under Chapter 6.95 of the—�jssftrv�SEP
Gdimou. Health & Safety Cuts, Sce ions 25505, 25533 and 25534. (......stun. that
if the building does not cumemly have stoma(. that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Oceupmay.
EXHAUSTHOOD(W/DUCD
PAID
Date Receipt Is
HEATING UNIT (TO FIRM BTU)
HEATING UNIT(OVER 100.(100 BTU)
.:
XMI
VENTILATION FAN (SINGLE RMID)
BOILER - COMP (311P OR 10T,000 B'IT)
ISSUANCE DATE
PAID
a 31983
yVf
/�
CITY U/. Vllr�
ISSUED BY:
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL H. SQ. M.
Ownermamhadmd agent - Dam