25378APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY -
CITY OF CUPERTINO UILD1NU -- stLh
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
ON BUILDING PROJECT' IDENTIFICATION
PERMIT NO.
25378
BUILOINGADDRE55�:].�
SANITARY NO.
APPLIGYDONSUBMHTALDAIn
R�% UNIT0 LOTN
-1_17>&4M
OWNERS NAME: P41ONE:
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CHITECT/ENGINEER: LICNO:
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QTY, ELECTRIC P R IT FEE
BUILDING PERMIT INFO
ECI
PERMIT ISSUANCE I �Q
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Natio license underpmvisionsof Chapter9(commencingwith
Section 701 of Division 3 ofmc Business and Professions Code. and my license is in
APPLIANCES- S ENTI
PANELS liJ
JOB DESCRIPTION
full force and effect.
License Clm Lic. N
UP T 2 1415
2 AM
Date Convector
ARCHITECTS DECLARATION1000
I understand my plans shall he used as public records.
AM
SQ. FT. FLOOR AREA
$/SQ. FT.
IONS ELECIR C
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIR IT/liv
I hereby affirms that I sin exempt from On, Carmelites License Law for the
TEMP. M G ST.
following mason. (Section 0031.5, Business and limitations Code Any city or c.only
which tw3uims a permit to consumer. alter, improve, demolish, as metals any strumurt
prior to in issuarrce,alm mandres the applicant for suchpernit to file a aigrtd statement
POWER DG
that he is licensed paramour to the provisions of the Connectors License Low (Chapter
9(commencing with Section]000) of Division 3 of the Business and Professions Code)
SWIMMING LELECTRIC
1A1111 1,
m that he is exempt aluminum andrhe basis far du alleged exemption. Any violmionof
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
' O W� Z,
OUTLETS -SWITCHES -FIXTURES a J
not more Nan five hundred dollars ($50%
❑ I,mowrcrofinepmNay.mmyemployee wilhwagmas irmlec.mpe lion.
NEW RESIDFNTIALELECI'R _SQ. FT.
STORIES
TYPE CONSTRUCTION
will do the work, andthe is nor is forsale (Sec.
or
he Com LicenseLaw do toa4, owner
end Professions Code: The Contromora License Law does not apply lf an owner of
ownempl hee ,pmvi iedta euchimMaements mtin w.rk oraffe for ughhis
wncmploy<a,pmvidedmatauchimpmvememavrtnm ininndedoroffertdforale. If.
GR
� i ,
S. U TS
e
TOTAL: 8' J
however, Ne huildingor improvement is sold within one yearofcomplction, theowner-
builder will have the burden of plowing that he did not build or Improve for puryose of
QTY. PLUMBING PERMIT FE
salt')'
❑ I, as ownerofthe property,am enelusivelyc.mrazring with licensed convectonm
oOD E
APN
construct the pmju'1 (Sec. 7064, Business and Predicted. Cade:) The Contractor.
License Lawdoes not apply manownaofpmpenywha builds mimproves Norton and
TE
PERMIT ISSUANCE
who contracts for such projects with acenuactot(s) reamed punuam lathe Contractors
License Law.
ALTER -DRAIN&VENT - WATER IRA)
) dl)
FEE SUMMARY
❑ 1 ala exempt under Sec. , B & P C fm rhia main
BACKFLOW PROTECT. DEVICE
O S E
SANITARY Y N
RECEIPTN
Dana Date -DRAINS
- FLOORROOFARP.A, COND.
, .
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
FIXTURES - PER TRAP
,❑ Thereby uffirmthmlheve ucertificnte ofcnnsentmxlf-inaum. oro cenifiale of
Worken'Compcnvlion linametceor a certified copy flamof(Sec. 3800, Iib C.) which
RF,CF.IPTp
PARK FEE Y N_
mmmitlemploya:undermispomit.
PaHiy#
GAS-EA.SYSTEM-I ING4OUTLETS
RECE N
BUII GDIV ION FEES
Company
❑ Certified copy is hereby famished.
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEkW
GREASMNDUSTRL WASTE INTERCEPTOR
GRADI
❑ Cenified copy is fled with the city inspoetion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOI FE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2WFT.
ENERGY PER
(This xetionneednm be completed Bran permit is furore hundred do)[. (SIM)
or less.)
WATER HEATER W/VFNT/ELECTR
I certify that in performance of the work for which this permit is issued, l shall
aot employ any Person in any runner so a 10 become sabjen to the Worker'
PAID
WATER SYSTEM(TRHATING
Compensubm awsof Califomis. Data
Date Receipi#
Applicant
NOTICE TO APPLICANT: IL after making this Cenificem of Exemption. you should
NEW RESIDENTIAL PLMB. SQ. PT.
TOTAL:
beemn. subject to the Workers Compensation provisions of the ""Iter Cade, you must
forthwith comply with such proviai.nsof this permit shell he deemed invoked.
p�
BUILDING FEE 39 a
SEISMIC FFP .1a,1 74
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the performance of
the work far which Ilia permit is issued(Sec. 3097, Civ. C.)
TOTAL: QO
ELECTRIC FEE IFS.S-V
Lenders Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FFP O
a
1 certify that 1 have read this application and state that me above information it
tree, Iagramcomplywithalleityandcoumy volume. and state law. relating ra
PERMIT ISSUANCE
MECHANICALFEH
y menter upon the
building construction, andhereby a.dlaria representatives alibis citme
above-mentioned property for inspection purposes. '
' ALTER OR ADD TO MECH, oD
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino e'am"
liabilities.judgments, mam.ndespersxa which tri any weyaccrve Bgai.r Bald City
AIR HANDLING UNIT (TO 10.000 CFM)
inIona uencco f fthia rmit.
°� .�
Y1s
^��
AIR HANDLING UNIT (OVER 10,000 CFM)
Si,name,AApplmem/ o rumor Dare
EXHAUST HOOD (W/DUCD a4-0
PAID
HEATING UNIT (TO I0).000 BTU)
IlAZARDOUS MATERIALS DISCLOSURE
Date eat is
HEATING ON IT(OVER I WOW BTU)
TOTAL: O
50
Will the applicant or future building occupant store or handle hmardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
Cade, Section 25532(q?
1:1 Yes ❑ No
BOILER- COMP (311P OR 100,000 BTU)
ISSUANCE DiTh
Will the applicanrorfmurtbugdingoccupenmxequipment ordevims which emit
BOILER -COMP (OVER I00,B00 BTU)
heard... air cortmormoa ns de0ned by the Bay Area AI Quality Management
t?
istnc ❑Yes ❑ No
SEP - 31993
NEW RESIDENTIAL MECH.-SQ. FT.
1 have had the humardicaus materials nNitiremera under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533 and 25534. 1 undersand that
if the building does not currently have a anent, that it is my responsibility as notify he
.: ry
ur
,recurrent of the requirements which must be met prior m issuance of a Certificate of
Occupancy.
ISSUEDBY:
Owner or authorised agent Date
TOTAL: 27.00
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