25631APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOIHNU-FLEe'MCAL
PERMITNO.
C
APPLICATION/PERMIT
PLUMBING - MECHANICAL.
�'I
5
BUILDING DIVISION
BUILDING PROJECT IDENJIF'ICATION
J o 1
MELDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
.O p
re— ve �
UNIT#
LOT#
6-13-93
L
OW RS�ANW: I�, HONE:
'
CO
CTOR' NAME: LCNO'
/e r-"'
N/C
CONTROL p
Z- /�
zr ;�
r- `�I
❑
MS4
CHITHCT/ENGINE : LICNO:
123� 7Z Is ��
CONTACT: PHONE:
"
.E ACTRIC'PERMIT
FEE
BUBLDG
ELECT PLU B MECH
SUANCE
LICENSED CONTRACTOR'S DECLARATION
ES -RESIDENTIAL
7201.]"AMPS
1pB DLSC0.IPTION
1herebysllirmthatImnlicensedunderprovisiensofChaptm9(commencingwithSeniors
70(10)ofD Business andand Profssi license is in77 fllfrceand
after Liu#
AMPS
Contractor
AMPS
ARCHITECTS DECLARATION
1 understand my plans shall be used m public reeads.
AMPS
p S IT FLOOR AR1C=�q `�
5/SQ. FT.
SIGNS ELECTRICAL
L VVV
PfI'��
Licensed Rofwsi... I
OWNER -BUILDER TION SPECIAL CIRCUIT/MISC.
)MI
from the Con License Low for the
1 hereby affirm that 1sam31. exempt from the Cocoons
0
0
following reason. (Section 7031.5, Business and Professions Code: Any city or coumy
Co
TEMP. METER OR POLE MST.
/1 0
whits requires a permit to construct, alter, improve, demolish, or repair any structureL
O VG
prior as its issuance, also requires the applicom for such Permit 4o file a signed statement
POWER DEVICES
that he is licensed pursuant to the Provisions of the Contractors License Lew (Chapter
VALUATION
9 (commencing with Section 7]0)) of Division 3 of the Business and Profusion Code) SWIMMING IMMMG POOL ELECTRIC
in he is esempuhere .. and the basis forth. alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant at y e civil Pa of
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars (S501). ❑ 1,asownemfihepmpeny,ormyemployeeswithwagesntheinolecompensadon,
NEW RESIDENTIAL FlECTR _SQ.Pf.
STORIES
TYPE CONSTRUCT ION
will do the work, and the non ure is not intended or offered for such, (Sec. 7044, B and roe
end Professions Cale: The Conuuctur's License Law does out apply to sea owner of
propcnywhobuildsor improvestmeron, andwhodimmuchwork himulforthroughho
OCC.
RES
wnemployea, pmvidedthatsuchimpmvemmtserenot inwndedmoffeted forWe. If,
.UNITS
however, the building or improvement is sold within one year ofcompletion, theowner-
TOTAL:
hander will have the burden of proving Nes he did oat build m improve for purpose of
sale.).
❑ Lanwn<ruf the pmpeny,am exclusively convening with licensedcontmctan to
QTY':.,
PLUMBINGPBRMIT
FEE
FLOOD ZONE
APE
construct the project (Sec. 7044, Business and Professions Cadet The Connewmrs
—
LiccnuLewdoesmtapply manownerofpmpanywhitmud orimpmves thereon,and
PERMIT ISSUANCE
whunrmmets Pasuch projects with a contractor(s) licensed putsuammthe Contractors
ALTER - DRAIN&VENT - WATER TPA)
FEE SUMMARY
Liver. law.
❑ I am exempt under Su. D & P C for this reueon
OUTFEES
SI
SANITARY Y —N—
RF.CEIPTp
HACK MOW PROTECT. DEV ICC
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF. COND.
..
SCHOOLTAX Y N
❑ 1hereby affirm that T have a certificate ofconunt toself-immrs, mnes"Bi at of
FIXTURES-PERTRAP
RECEIPT#
PARK FEE Y N
Waken Compenwationlnsurance aecerified copy thereof(Ses. 3800. Lab Ctwhich%
ars ell employee's under this Permit.
i Policy #
GAS - EA. SYSTEM. INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHF,CK FEE
❑ Cenifed copy is hereby famished.
GRADING FEE
❑ Certified copy is Bled with Ne city inspection division. GREASEnNDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not becomplevA ifthe Permit is torose hundred dollars ($100) SEWER - SANITARY - STORM EA. 200(4.
or lea.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECfR
not employ my person in my manner so in to become subject to the Workers'
PAID
Compenamionlawsof Celifomia. Date
WATER SYSTEWIREATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If. Mer making this Cenificam of Exempmen, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
haome mbjem ro the Workers Corpsman.. provision of the labor Cade, you must
forthwith comply with such Provisions or Nis pemdt shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfarrance of
/
ELECTRIC FEE
the work for which this Pemrit is issued (Sec. 3097, Civ. C.)
Ixodes Nene
Lenders Address
QTY.:
MECHANICAL PERMIT
FEE
PLUMBING FEE r'
1 certify Nat 1 have road this application end state that the above information is
MECHANICAL FEE
coned I agme to comply with dl city and ..my ordinances andsmm laws In., an
PERMIT ISSUANCE
CONSTRUCTION TAX
building consvanion, and hereby authorize repmemundves of this city m enter upon she
move -mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
(We wave. indemnify and k the City of Cupertino against
limbi' s,jud ts, costsun may in a y weyaccrveaguinstsaid City
AIR HANDLING UNIT(T010,000 CFM)
nscque eofthegrnt is pew
AIR HANDLING UNIT (OVER 10,000CTIM)
/U
PAID
more of Applicant/ n Date EXHAUST FOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNITOO 100,000 BTU)
Date Receipt#
Will the applicant or future building occupant stare or haMle hazardous material
HEATING UNIT (OVER 100,000 B'N)
n defined by the Cupeninn Manicipal Code, ample, 9.12, and the Ilealth and Safety
Code, Section 25532(x)7
❑ Yes ❑ No
VENTILATION FAN (SINGLE RPSID)
ISSUANCE DATE
BOILER- COMP(3HPOR 101,000 BTU)
Will theapplicantor future buildingacupant useequipmentvrdevices whichemit
hawdous aif contaminants a defined by the Bay A. Air Qudity Management
BOILER-COMP(OVER 100,000 RTU)
Decoct?
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
A 4 D
PAID
]cnts
1 have read the humrdous materials requircmunder Chapter 6.95 of the
r
Calif and. Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand than
if the building dos not currently have a mnmt, that it is an, responsibility minify the
occupant of the rearm meals which must he met prior m issuance of. Certificate of
OCT � �
Occupancy.
I{SU
Owner or authorized agent Doe TOTAL:
OFFICE