25257 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILTHNG7VIEI TRICAI. PERMIFNO.
PLUMBING-MF.CIIANICAI.
BUILDING DIVISION APPLICATION/PERMIT - BUILDING PROJEC5 C
Pf1DENTIFICATION J J
RUILDINO ADDRESS: l(/�1 n/'�� `L[1 SANITARY NO. A1PPLICAT'IOONN�SUBMfITALDNIF.
�.KCCI IUNITM LOT# L2 Lyq
O N' SNA. I PIT
0N� �I, Rt�rJR'$NAM I^� L N
11`1 , 1 NIC CONTROL
ARCI IITECf/EN INFER: LIC NO: ppf]@ESS' I LJ. ❑
CONTACT: PHONE: 144 II II //ll PCT! I Cl BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MF.FII
PERMITISSUANCE El 11 1:1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, JOB DESCRIPTION
pp•Z 1herehyaffirmthat l and licensedinterprovisionsMChapter9(commencing wit
�i10p fall form
ormandcf Divihinn3of the Business and ProfeseionsCWe,and my license is in PANELS �a
y U full force and a t. "'�%V�.`pJ•`�
QFyW
Lima c lush-- I.ic.N 2 -0200 AMPS
20101
vi,Q=y Dam Contract -1(%10 AMPS
SQ.FT.BOOR AREA E/$Q.FT.
ZOy'� ARCHITECTSD LARATION OVER 1000 AMPS
p Z_C) I understand my plans shall be used as public recnNs. ra
W N
Qg '2 Licensed Professional SIGNS ELECTRICAL I r^A� 'U
Egli, OWNER-BUILDER DECLARATION SPECIAL CIR UITMISC.
xMliU I hereby emrm that I oat exempt from the Contractors License Lew for We n ,..a II II � �
u1�r tr.y following maom(Shation 7031.5.Business and Professions Code:Any city or county TBh1P.MEfEROR POLE WST. / `vu C U
which"mers a permit to construct,after,improve.demolish,or repair any structure
prior to its issuance,also requires to applicant for such permit to Man signed statement POWER DEVICES
p Iha(he is liocnsed pursuant to the provisions of the Conhnmors license Law(Chapter
SWIMMING POOL ELECTRIC
iron 9(commencixemwith Sation7000)he Division Sof to alleged
emptio Professions Code) _ VALUATION
,-,y oration 7031.5 by ttcmfmmand the basis nt far.permit
subje este plicaniean.Any ivil penalty of OUTLETS-SWITCHES-FIXTURES
T not more
door 6y any hundredollr,($50mmitsubjec0the applicannoecivil penaltyof
Q not nmrelh.n five hundred dollars($500).
W ElI,asowneroftepmpmy,ormyemployaswithwagesatbeirsolecompmation, NEW RESIDENTIAL ELF.CfR _SQ.IT. - S'T'ORIES TYPECONSTRUCO'ION
per,�3 will dote work,andtestruclure isnot intended oroffered for sale(See,7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
propeny who builds or improves thereon,and whodoes such workhimselfomhrough his OCC GROUP RBS.UNI I'S
own employees,provided That such improvemems me not i....dedor offered for sale.IL
however,the building or improvement is sold within oneyearofcompletion,to owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asowner affair propeny,sm exclusively contracting with licensed c....cmrsm QTY. PLUMBING FERMIT ITE FLOOD ZONE APN
construct the project(Sec,7(A4,Business and Professions Code:)The Contractors PERMIT ISSUANCELicense Law does not apply m an ownerofpropeny whir builds orimproves thereon,and
who contracts frrsuch projects with a comeactor(s)licensed pursuant othe Conammes
Lumore Law. ALTER-DRAIN&VENT-WATER(FAT ITE SUMMARY
❑ Lam exempt under Sec. ,B&P C for tis man HACK FLOW PROTECT.DEVICE U-.ID •I:
SANITARY Y_N
Owner Date RECEIP #
GRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATIONN
I hereby affirm tetlhave acrnificnte odconse iCLARATION SCHOOL TAX Y f conxmmself-insum,ora certificate of FIXTURES-PER TRAP RECF.IYI'#
W rkers'Cnmpumsmien lnsumncaoraaenifieA wpyth.rwf(Seo.Jg00,l.ab C.)whi.h PARK FEE Y
ovuymdyoye�ersunde sq�pm,�t. /a'YYTTiT
BIT C
Poy#BGAS-FA.SYSTM-IINC.40IT.ETS G DIVISION
FEES
Company
GAS-FA.SYSTEM-OVEJi4 THAT - PLANCHECK FEE
❑ Collided copy is hereby famished.
Certified copy is filed with to riry inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXF.MPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tnk.cdion needful becoarrehud lfte pemlit is feature hundred dollwa($1010 SEWER-SANITARY-STORM 11A.20017. ENERGY FEE
or less.)
E ccnify that in to performance of the work for which this permit is issued,I shall WATHR 11 HATER WNHNT/HLECTR
not employ any person in any manner so in to become subpar to to Workers' PAID
z Compensatiofl.trawmCelifnroia. Data WA'IARSYSTElsb BEATING Date Receipt#
Applicant
z0 NOT ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
IA become subject mte Workers ComPershom.provisfonsofte Labor Code....must
� ; forlbwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm that tem is a construction lending agency for to perearromco of
to work for which this permit is issued(See.3(1)7.Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
OF Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEL'
U E certify that I have read This application and state that to above infommtion is MECHANICALFEE I�
>" Was. ennect. l agree to comply with all city and county ordinances and state laws mladng to PERMIT ISSUANCE O
y building construction•and hereby awhoriaerepresematives ofthis city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned pmperty for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to saveu indemnify and keep harmless to City of Cupertino against
liabilities,judgments,costs undexpeness which may in my way accrueagainst said City AIR HANDLING ON]']-(TO 10,00)CFM)
e In...c of the grafting of this rmit. r
`.x AIR I IANDLING UNIT(OVER 10,000 C17M)
J---of Applican/ComrurorDat EXHAUST 11001)(WNUC)
PAID
GAZARDOUSMATERIA ISCLOSUR HEAPING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building Occupont amre or handle nus material HEATING UNIT(OVER IIXI,IfXI ETU) TO"I'AL:
a defined end by the Catarina Municipal Crile,Chapter 9.12, the Health and Sefcty
Cale,Section 25532pmp
❑Yes No VENTILATION PAN(SINGLE RHSID)
BOILER-COMP(JHP OR 100,0011 BTU) B.ISSIJA�CbDATE
Will teupplicnnl urfmure building oecupnnt use equipment ordavices which emit IYf"- l��$ IIdJ
ahadmix it contaminants es defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100.00o BTU)
District?
EIYes XNo NEW RESIDENTIAL.MECII. SQ.n. DEC
nk/G VCCn
2 1993
I I have read the whourdous materials requirements under Chapter 6.95 of the r�
Caldron.Heauh&Safety Code.Sections 25505,25533 and 25534. 1 made..mnd that C 7 Ur V V rCfl I IIIQ
if the building does not currently have a tenant that it is my responsibility to notify Ire
ccepam of the requirements which must be met prior to issuance of r Cell ficatc of
Occupancy. ,�/ywww# AIf`�
OwnermindadeMugent Dam TOTAL: ISSUED BY: V lJ1✓ P 1