25245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPE RTINn .B N'f-MECHANICAL CAT,- PERMIT NO.
APPLICATION/PERMIT PLBMBING CI IDENNIFIC _
NUII,IIINC DIVISION ISUII.DINC.PROJR01'IIIRN'TIFII:ATION 25245
BUILDINGLADUR(F S: /ic SANITARY NO. JAPPLICATIONSUBSurnALDATI.;
OV a� UNIT'# LO TO
OWNERS NAME: s PHONE: COM'RACI'OR'S NAME: LIC NO: lJ
N/C CONTROLM
ARC]IITEC'f/I!NGINIiI'.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
6$41q GGv'E 14xgj I 6) PERMIT ISSUANCE BLDG . ELECT' PLUMB MHCH
V ❑ ❑ ❑ ❑
LICENSED IsDCOMRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL.
I h700 flan Wml 3 ofthnsed under r p gwi JOB DF.SCRIPI'ION
pKZ yu pnvisionsnfChu mr9(commencin th
�a10tu0 Section 700o)of Divisionlof the Business wJ Professions Cad e, my license is in PANELS �O r, /�
Qzwfull far cc and eBxl. ` D welt
FZW I.iccnse ass 1,ic.p IIP TO 200 AMPS
vsQy Dram — Cnnmittar 201-IIIf1B AMPS
Z CO,=Z RCH ITECT`S DECLARAT N OVER 1000AMP5 SQ.FF.F OR AREA $/SQ.FT.
O Z— I understand my plans shall be used as public words.
q'� Licensed l'ndessional SIGNS ELECTRICAL
BCW OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyF - 1 hereby affirm that 1 am exempt from the Committers License law bribe
tsf3Qm fallowing motion.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
pJ'y which m ire,.permit m rindionolish,et,site,,improve,demi r mpmr any smudure -
;!(Y� prior m it,lsmancem'.machines the applicant for such permiuo file.dowdy statement POWER DEVICES
amps that bets licennedpurman to the provisions ofihe Contractor's License Law(Chapter
d o4 4)(commencing with Section 7000)of Division 3 crime Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
mMm nr Part he's exampnherefromand the basis for lmalleged exemption.Any violation of OUTLLTS-SWITCHES-FI%'TURES
�ZQ Section 7031.5 by any applicant fora permit subjects the applicant macivil pmoltyof
� 0
not mart than five hundred dollars(85(18). NEW RESIDEN7IALELECTR _S FT.
W�0 ❑ I,mowneroflhepmpM,ormyemployeuwithwagesastheirsolecompens.tion, Q' STORIES 'IYPECONYTRUCTION
d will do the wnak,amd l]restructure is not intandielmoffend hostile(Sec.9144,Business
anA Professions Code:The Contractors License Lew does not apply m an owner of
pro,,who buildsorimprnves theteagand stand.such workhimsiefmthmughhis
own employess,provided lhatsuch improvementsuenotintendedoroffered facials.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofcamplmiom theawner-
builderwillhavetheburdenofprovingthathedidnotbuildorimprove for purpose of 'TOTAL: -U
sale.).
CI 1, ex
I,asowner ufths property,manclusivelymarrating with licensed contractors to QTY. PLUMBING PERMIT FEE FtOODZONE APN
msmum the project(Sao.9044,Business end Professions Code)'Phe Conouchn, ,l
icenscl.aw doesnol apply loan ownerofproperty who builds orimproves thereon,aafndd PERMI" E 1
who commnaforsuch projects wilbaconrrnnar(s)licensed pursoantiolbe 111 _7GR':pRA1N&VEM'
License Law, h �. I /' WA (EA) FEESUMMARY
❑ I anh excmPl under Scc. ,B&P C for this OUTSIDE FEES
*GAS.
'Trg:pEvur SANITARY Y N
Owner Dale ' s - RECEIPTNWORKMAN COMPENSATION DECLARATION R 00 SClI(IgLTAX YN
I hereby affirm that l have acmificate ofetursent mself-insure.orace'druid J RECEIPT#Workers'Compensation Insuranceo a cerli0ed copy themof(Sm.3g 1,Lb C)` M pAHK FEE Y Nrovers all employee's under this pCmhil. ��.,_-_ EM-I INC.4OI)TLETS RECEIPI'a
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM. 4 r
PLANCHECK FEE
❑.Certifiedcopy it hereby furnished.
❑ C<rtifed copy is filed with the city inspection division. GILEASIVINDUSTRI.VrASAMRFERCEMPT& GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE SOILS FEE
(Mis section need not has completed Brad permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM Ep.200FT. ENERGY FEE
less.)
I evoily shat in the perfortmore afthework for which this petard is issued,l shall WATER It EATER W/VF.NT/ELECTR
not employ any Pearson in any manner in es in become subject In the Wmilmm' PAID
Compensation Lawsof Califomia. Data WATER SYSTEMTRGTING Dale z Receiplp Applicant '
NOTICE TO APPLICANT:If,after making this Cmi0cate of Exemption,you should NEWRESIDENTIALPLMB. SQ.PT. TO'T'AL:
Cl~ become subject to the Workers Compeasaton provisions of the Labour Code,you must
a > forthwith comply with such provisions or this permit shall he domed revoked. BUILDING FBI!
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby Off that Were is.construction lending agency for the performance of
U O the work far which this permit is issued(Sm.3097,Civ.C.) TOTAL: L'LEMRIC ITE -O D
Lender's Name
C U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I redity that I have read this application and state than the above information is
convert,l agree to comply with ell city and county ordinances and some lows mining to PERMIT ISSUANCE MECHANICALME
I--' building construction.and hermyamhorise reumummtvesoftheckyor enterupnn Ne
V y ubnve-darrownedpropcny for inspection puToses. ALTER OR ADD TO MECH. CONSTRUCTION TAX
F7 (We)agree to save,indemnily and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may roomy way accrue ugaidet said City AIR HANDLING UNIT(TO FROM CFM)
mersequc a of the Starting of this Permit.
� AIR HANDLING ONIT(OVER BLO00 CFM)
Signa cant/Contmcmr Dale EXHAUSTHOOD(W/DUCT) PAID f7-
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt tl
Will the applicant or future building occupant store or handle hamNous material HEATING UNIT(OVER HARBOR HI U)
'TOTAL:3D'�U
as derided by the CuLino Municipal Cade,Chapter 9.12,and the Handth and Safety
Cala,Section 25532(.)1
❑yet ❑No VENTILATION PAN(SINGLE RESID)
OWBTIH II 5 A'fE
Will thcepplicantorfmurebuildingaccupunt uuryuipmcntordeviceswhich ehnit BOILER-COMP(31IPOR 100, -
hromdous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000BTU)
0 DistrictJUN 2 31993
❑Yea ❑No NEW RIiSIDEN'TIAI.MECH.—SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the CI IY Ur tiUl'tnI I(gU
Cnlifomia lleulth&Sufny Cede,Sedans 25505,25533 and 25534. I undommad that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must m met prior to issuance of a Cenifcam of
Occupancy. 1,s
Owner or aulbonised agent Data 'TOTAL: ISSUED BY: