25801 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII'O PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PING PRODB NU CT IDEANIFIC 25801_
BUILDING PROJECT IDRNTIFICATION
BUILDING ADDRESS: ek) ff^/g5^y SANITARY NO. APPLICATION SUBMITTAL DATE
SIL UNIT# LOT# 11 �
0 NER E: PHONE' CONTRACfOR'SNAME: LIC NO:
Vfa/�
M'-nO 2 NIC CONTROL.#
RCHITECIENGINEER: LIC NO: A SSS: 1:1'n.af+e�LTo D Z
CONTACT: PHONE: .. BUILDING Y PERMIT INFO
QT •;i '+ EEE�CTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE F-1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pdz
Ihereby offirm that l em licenam underprovisiansof Chapter 9(corrunenciagwith
On Section 7000)of Division 3 of the Business and Professions Cade,and my license is in PANELS ^ -
p�WVy fullfam.and p.Classeffect. Lic.# UP TO 200 AMPS IPl/YJ 0
h Q Date Convector 201-I"AMPS 11✓I��PPPtt
Fye, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Ff.FLOOR AREA g/SQ.FT.
0 Z PJ G 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
aF vs
Sy W V OWNER-BULDER form
m the CoATION SPECIAL CBfCl1IT/MISC.
04 1 hereby affirm that 1 oro ,Business
from the Contractor's License Law for the
W 3 4 y following reason.(Section 703L5.Business end Profusions Code:Any city or countytura TEMP.METER OR POLE INST.
�; which requiresapermit lecher thealter.improvesdemolish,oreepairany structure
!!1T0 prior ce I,licensed pulsmttorth throviiapplicant fthe C pamitto file a.Law urement POWER DEVICES
ly 3a�QO flu9(cm isncingwpunumtto Neprovisionsof the Ce Business
License Lew(Chapter
44 s 9lrommencing with Satire 7000)af Division 3ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VAI_hj&&ON
x Nor he is exempt ducal..and the basis far rheallegW esamplim.Any violation of CIL—
ttOIfILETS-SWITCt(NS-FlXTIIRES
p. G Section 7031.5 by any applicant for a permit guhjacts the applicant to a civil Mruhyof
aC0 not matron five hundred dollars($500).efRESIDENTIAL ELECIR .
e ❑ I,asownofthepropeny.ormyemploymswith wages utbaboolecomperwNEW 5Q PT.fion, STORIES TYPECONSTRUCIION
63=e will dmhe work,and the structure isnotinunded oroffered forode(See.7006,Business
r .and Profeasions Cale:The Contractor's License Law does not apply an an owner of
pmpeny whobuilds orimpmvu thereon,andwhodmasuch work himulforthrough his
OCC.GROUT' RES.UNITS
wnemployes,provided that
pr ve impis sold within
t en:not intendedmoffered intsal nlL
huildar ,illhathe vl the burden
of moving
mentgmt he did noneyem or improve for
theowner- TOTAL:
W..), will have the burden of proving that he did not build or improve for purpose of
W..), QTY. PLUMBING PERMIT FEE
❑ Las owncrnf lhepmperry,amexdusivelycano-uting with loomed mntrvctorato FLOOD_ZONE APN
construct the project(Ser.7006.Business and Professions Code:)The Contractors
Liceme Lew dcesnot epplyman ownerofpropery whobuilds orimprovesthereon.and PERMIT ISSUANCE
whoccomets forsuch projects with a contractors)lianeed moment tothe Conraaors ALTER-DRAIN&VENT-WATER MEA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. .8&P C for Chia rcasm BACK FLOW PROTECT.DEVICE T 1 E
ANITAAY Y N
Owner Data DRAINS-FLOO ; F,Iq FA;CdN m_ J"7
I. RLCCIPT#
WORKMAN COMPENSATION DECLARATION CHOOL TAX Y N
❑ Iherehy a(fem thatl M1ave acenificele ofcmanno self-insurc,on emifeau of FlXTURES-PEN RAP ) RECEIPT#
Workers'Compensation Instruments carolled copy thercef(Sce.381X1,Lab C.)which I RK PEE Y N
polars all employee's under this permit. GAS-EA.SYSTE sI 1NCA0 RECF.IPTp
icy p BUILDING DIVISION FEES
CampanY GAS-EA.SYSTEM-C�V���J1) PLAN E.CK FEE
❑ Cenifhed copy is hereby furnished.
❑ Cenifim copy is fled with the ciry impaction tliviron. GREASFgNbUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionncednot ecompleted ifNepermit is foronehundreddollan($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that..the perfomunce fthe work for which this permit a,is issued,l shell WATER HEATER WIVENT/ELECIR
not employ any person in any manner so as to become subject to the Workers' PAID
z Compens
samm"wof California. Date WATER SYSTEMITREATING Date Receipt#
Applicant
z 2 NOTICE TO APPLICANT:If,ofle,making this Cenifeaseof Exemptiogyoa should NEW RESIDENTIAL PLMB. SQ,FT. OTAL:
U) become subject to the Workers Compenudon provisions of the Labor Code,you must
� > fonhwich comply with such provisions or this permit shall be deemed FE
revokes. BUILDING E �•
Lq Q SEISMIC HIE
CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat NemisaconswctionleMingagencyfmO performanceof
Penni TOTAL: ELE FE
U O
the work for which this t is Issued(Sec.3097.Civ.C.)
fender's Name pLUMBIN FEE
0 - Lenders Address QTK MECHANICAL PERMIT FEE
iI
U 1 artily that 1 have rend this application and stele that dre above information is - MECHANICAL FEE
�" Wtorted.lagaememoplywithelleityandcounty ordinsnaaendsule laws relatingm PERMIT ISSUANCE
�-' building comwctiom and heeebyauthomse se,manutivesaflhis city to amearman the CONSTRUCTION TAX
U ,z above mentioned property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify and keep harmless the City of Calmar,err,against
luddlitiesjidgcoam,o.m.rad eapmus which may many wayacerueagafnstmid City AIR HANDLING UNIT(TO 10.016)CFM)
f the grunting of this Permit. a AIR HANDLING UNIT(OVER I0."CFM)
41 Signen� on- 4 eawK ` au EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DIS OSURE HEATING UNIT(TO I00,IXXIBTU) Data Receipt#
Will the appli<am or forum buildin naupont a e m handle haaeNom mammal
as defned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0011 BTU) T 1^
Code,Section 25532(a)Y
13 Yee 13 No VENTILATION PAN(91NOLE Rp$ID)
Will Ne npplicenc orfusurchuildingmcupent use eyuipmem ordevicawhichemit
BOILER-COMP(3HP OR 10(i BTU) ISSUA CE DATE
heardous or co munimnu as defined by the Bay Arco Air Quality Management BOILER.COMP(OVER 100,000 BTU) D
Dist/uR
❑Yea ❑No NEW RESIDGNTIAL MECH. SQ.FT.
1 love rad the Safe,,
Core,
modals rcquimnrnu under Chapur,understood
of the
DEC ' 2 1993
California Health&Safety Cafe,Sutions 25505,25533 and 25534. I understand Net
if the building does not currently have a learnt,char it is my responsibility to notify the /.
occupant of the regaincor ms which must be met force to issuance of a Certificate of VIII V! V IV V
Occupancy.
Owner m mihorxed agent Data TOTAL: ISSUED BY:
OFFICE