25032APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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L. I)-IAR`T-E111, R A'
CITY OF CUPERTINO25032
APPLICATIONIPERMIT PLUMBING - MECHANICA
'BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
PERMrINo.
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
G W D ✓Q UNIT p LOT# 3
.x/3/93
OW SNAME: PHONE:
CONTRACTORS NAME: LIC NO:
N/C
CONTROI.p
❑
ARCIIITECf/ENGINEER: LIC NO:
ADDRESS:
CONTACT. PHONE:
�j //, I,.
ke � �+
QTY. ELECTRIC PERMIT FEF,
BUILDING PI?RM1T INFO
CH
BLUG� LEC{ PLUMB ME❑1
'LEY
f PERMITISSUANCR r
v-1 + 1 •
tL-Et/ rL�l
1042
100
ty
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LICENSED CONTRACT'OR'S DECLARATION
IherebyuffinmhatIamlicensed underprovisionsof0apter9(commencingwitb
Section 9000)ol'Division 3 of the Businc,,Omd Professions Cudc,md my license is in
full force and effect.
License Class Lic.#
APPLIANCES - R .IDE
A
a( 1 , (j"� JOB DESCRIPTION
%9tlC7'T�a�Lg -Ep PA,,,,; It Roowt
1 .�
BAR
PANELS
UP TO MI
- 1 MP.
RI I'S
I
pp
3E W
. i
Data Compactor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records.
SQ. FT. Pl.00R AREA
E/SQ.IT.
5 ELF.CIRICAI
Licensed Professional
)RUNN
. w J
I q 0
l0KK
I -m
.ZT
OWNER-BUILDE0.DEC Contra t.
I Hereby affirm that 1 am exempt from the Cnmmeor's License Law for e
following reason. (Section 7031.5, Business tend Professions Code: Any city or ca ry
which requires a permit m constrvet, eher, improve, demolish, or region any arra
prior to its issuance, also requires the applicantorsuch Permit o fleasigned statament
thin he is licensed pursuant to the provisions of ghc Cotnmcures License Law (Chapter
9(commencing with Section 7") ofDivision 3 of the Business and Professions Code)
or that he is exempt therefrom and the basis fought alleged exemption. Any violation of t
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
ECTAL CI IT/MISC.
A 1 / e I -
F-Itlt7 ' Ks
TEM ETER OR POLE INST.
WER DEVICES
SWIMMING POOL. ELECTRIC
VALUATION
L1�pi�lC s,�+aQoO �{�
VV
OUTLETS- SWITCHES-FI%TLRES •
0
not more than rive hundred dollars ($501).
Lnwnernftheprompe cation,
CIas employeeswith wages extheirsoleco
%
.FT.
NEW RESIDENTIAL ELECIR SQperty,ormy
STORIES
TYPECONSTRUCTION
Lo
willdothe work, and thestmctoe is not intendedoroffered forsele(See. 9044, Business
and Professions Code: The Combacoes License Law does not apply to an owner of
0 Q L{
property who buildsmimproveathereon.amd whereat, such warkhimselforthrnighhis
twnemployees, provided that such improvememsare not intended oroffered forsale. If,
OCC GROUP
RES. UNITS
).
however, the building or improvemrnr is nsld within one yearofcomplegian, the owner-
builder will have the burden of proving that ha did nor build or improve for pro,aw, of
ole /
I, av owncrofthe property, amexclusively contracting with licensed comractnrs to
I
QTPLUMBING PI7RMIT FEE
Y'
FLOOD ZONE
qPN
construct the project (Sec. 71144, Business and Professions Codc:) The Contractors
Lionel wdocsnotapplyioanownerofpropmywhobuiIdsorimprovuthereon,and
I PERMIT ISSUANCE
who contracts for such projects with aconwcorts) licensed pursuant to the Contractors
License
se Law.
ALTER- DRAIN&VENT - WATER (I'A) /'•
/
PEE SUMMARY
❑ 1 mn exempt under Scc. , B & P C for this moon
SACK FLOW PROTECT. DEVICE
O
SANITARY Y N
Owner Date
WORKMAN COMPLNSATION DECLARATION
pRA1N5-FLOORROOFARCACOND.RECEIPT'p
. , ,
SCHOOLTAX Y N
❑ Iherehy affrm thotJ nnveacenillcmc of con.aem mselEimurc. orecenipcurc of
Workers' Compensation Insurance or a certified copy thereof(See. Jg(p,LabCJ which
roosts all employee. under this permit.
Policy p
RECEIPTp
FIXTURES - E'ER TRAP
PARK FEE YN
RECEIPfq
GAS -FA. SYS I
BUILDING DIVISION FES
Company
GAS -PA. SYS M"O F. 4 i
LANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Cenified copy is fled with the city inspection division.
GRF.ASMNDU S' MC M
RADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS QEF.
COMPENSATION INSURANCE.
SEWER - NITAR -S'
ENH YFEE
CMissectionnadnmbecompletMifthepnmirisfmonehundr dollm(5100)
or leu.)
WATER HEATER WryEM'piLECfR
I certify that in the performance of the work for which this permit is issued, l shall
nut employ any person in any manner so as on become subject do the Wmken'
PAID
z
0
Coni'mtionlnwsaf California. Date
Applicant
WATER SYSTEM)TREATING
Data Receipt#
NOTICE TO APPLICAN'I':If. after makingthis Cenificmeof Exemption. youshould
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
>
become subject,, theWorker's Compensation provisions at Labor Code,you must
fonitwithcnmply with such provisions or this permit shall Na reamed revoked.
BUILDING FEE —�
SEISMICFEE
(]
CONSTRUCTION LENDING AGENCY
z
F
LUk1I
z
Iherehy affirm that there is a construction lending agency for the performance of
ihe work for which this permit is issued (Sac. 3099, Civ. CJ
<nders Name
T AL: ��
ELHCTRICFF.H
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Address
cattily that I have read this application end state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relaringo
bthose-mentionedfunies hercbyawhonsooses. tivesof thio cityoen¢r upas the
above-mentioned funniest inspection and propos a.
PERMI"f ISSUANCE
MF.CI IANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree m save, indemnify end keep the City of Cupertino against
liubilities,jndgmenrs, coats and expn¢cv which may in any way accrue against said City
may baby
AIR IIANOLING UNIT (TO IO,tXq CFM)
in cunaequenc ,,f the granting ofthis emit.
- ) n
i
AIR HANDLING UNIT(OVER IR" CFM)
nmureof Applicam/Cmntmcmr Data
EXHAUST HOOD (W/DUCIj
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dare Receipt is
Will the applicant or future building occupied store or handle haordous material
as depend by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IM.W BTU)
TOTAL: j.
Cada, Section 25532(e)4
❑ Yes 13 No
L
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR I00,11IX1 BTU)
ISSUANCE DATE
RrP {7
Will rhenpplicanror future buildingmcupam uaee9uipmemordevicea whichemit
baserdooa air contaminants as defined by the Bay Area Air Quality Management
DistrirtP
BOILER - COMP(OVER 100,000 BTU)
❑Yn ❑No
r M a
NEW RFSIDPNTIAL MUCH.—SQ,FT.
I have read the hnmrdma materials requirements under Chapter 6.95 of the
California I lealth & Safety Code, Secu
Serious 25505.25533 and 25534. 1 nderstandhat
t
MAY - 3 1993
if the building does not currently have a tanant. that it is my responsibilityo notify the
occupant of he ra uiremems which most be met prim an issuance of a Certificate of
Occupancy.
nI I
Vut-
ISSUED BY:
Owner or anthodxed agent Data
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