25474 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-—FLFGYRICAL PERMI'I'NO.-
APPLICATION/PERMIT PLUMBING-MECHANICAL 25 /I
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L J 4 fA
�
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER ME jo R'S NAM' 1 O
1 NIC COMROLR
ARCHI i
TE-C7U`EN%fflEER: LICN DDR S: / ❑
CONTACT: PIIONE: TY, ELECTRIC PERMIT G/JCY FEE BUILDING PERMIT INPO
AAA �S LD ELECT PLUMB MECCH
C L� PF.RMITISSUANCF,
LICENSEDCOMRACI'OR'SDECIARATION APPLIANCES-RESIDENTIAL - 10 OCSCRI O
p02 Ihe").ftmmatl antlice B.sindttprovi»iomafChopttt9(cammeming wish �n^ — _ a
�s100 Section]OIXI)of Division lofthe Business and Rofessions Cute.and my license is in ppNP15 /Nf�/(.(�A/'
=WUF. fullforttnndeffec n
<U License C1. I.ic.N p✓ UP TO 203 AMPS L_
m Q y Date Contncmr 201-1000 AMPS 44
I'-,oz CIII' S fl SQ.FT.FLOOR AREA S/SQ.FF.
zO,ia— OVER IIXIO AMPS
Oz—D u d r haE antic to a
f,ret F-tY m el"',S SIGNS ELECTRICAL s
< Llct PmIcAurml
�p�KG OWNER-BUILDERDECLA A ON SPECIAL CIRCUITIMISC.
.X I hereby affirm that I ran exempt from the Contractors License Law for the
following mour n.(Section 7G31.5.Business and Professions CMe:Any city moronity TEMP.MM. R OR MLC INST.
F C which reyuircs n also
m wmtmet,alma improve,h Permieh,or repair nay tatucmrc
'WY� thione itsissuance,
remede,alsoremthethe appliumfor e Cmntramiuo License
La statement POWER DEVICES
lode. < that he is licensW pursuant mthe provisions of the Commnnr''»License Law(Chapter
440 ' 9(commencing with Section 701 of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC /� VALUATION
or h7i31.5 by t Nercfmmanf thePeriefonheasehWexemNi to civiny lPnion of OUTLETS-SWITCHES-FIXTURES )ti(/��/'� Ate'
FZ5' Senior]031.5 by any applicant for epermit subjects the applicant toucivil penalty of //"" v
Q of more man five handled dollars($500).
�eZO NEW RESIDENTIALELECTR —SQ.FT.
m n❑ .thew crofinepmperty,ormycmployceswith wogehm meirmlecompBusinen, STORMS 'I'YPL'CONSTRUCTION
pW-3� will dothewons Codes he Contiactora License La do fnntapple.'A14n owner
of
ss
and property
adualm Code:The Contractor License Law does or apply lf an owner of
own erywyees,prism ed that such improve whs moors twmkhimsered through his CGROUP RIS.IJ ITIS
employees,the buildiniorimprovcment is improvementsmoorne earofeuroUercd formic. r-
bit der
however,the building f,mentishathwithinoneyear rimprole forpacowner- TOTAL:
bale.). wit l bout the burden of proving the he Aid not build or improve for purpose of
ole.).
❑ I,us owner nf the property.am exclusively contracting with licensed convacmrn to QTY. PLUMBING PERMIT FEE FLOOD ZONE AI'N
construct the project(Sec.7 W ,Business end Profewiars+Culled The Contractors PERMIT ISSUANCE
Limits,Law does not apply man owner of property who builds or improves thereon,and
who contracts forsuch projects will,a contractors)licensed pursuant nthe Conlraemr'» ACII?R-DRAIN&VENT-WATER fA) "
Li=tre Law. L' FEE SUMMARY
❑ 1 Cm exempt under Sec. ,Il&1'C for this reason BACK FLOW PROTECT.DEVICEI f OUTSIDE FEES
A ITA
Owner Data 'N
DRAINS-FLOOR,BOOP.AREA,CONI.
WORKMAN COMPENSATION DECLARATION C L A N
❑ IM1erehy affirm the lhuveecrnifcn¢of canscnOn.+clGinsure,or ucertifetm of ' 'M t
IgXTURFS-PF,R TRAP
Workers'Compensation Insurance nracenifiW copy thereof(Sce.3R0),Lab C.)which ARK FP.hf�
covers all empl 'a m OAS-EA.gYSTEM-1 INC.40UTLET$ NCClillvl'is
PulicyN TNG DIVISION I?ES
Company GAS-EA.SYSTEM-OVER 4(EA) DME
❑ Ceriliedc pys iercb umtshed.
❑ CertifieA copy is flW with the city impenion division GREASE/INDUSTRL WASTE.INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE _
(Thisimetion raccoon be completed ifthe permit is foram hundrecidollars[$100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify thW� ff anceof to,vork for whit this pe is+ cd,ishull WATE0.HEATER WNFNT/ELECfR
not employ n mann a+I�1 « , t Wmkc. PAID
Comps ti Dat •••/// WATER SYSTEMOBEATING Date Receipt#
z � NOTICET A , fterm ing misCmific:eff,nemaption.you should NEW RFSIDPXI'IAL PLMB. SQ.FT.
(✓ � b«o me sub ccttn the Work or'a Com tionprevisionsof the Leben Code,you must
TOTAL:
tensa
� > forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE OV'
C Q CONSTRUCTION LENDING AGENCY SEISMIC FEE /aL
Vz 1 hereby affirm that them is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3097,Civ.C) TOTAL: ELECTRIC FEE
Lenders Name
U.
E •"' Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING TEE
U I clarify that I have read this application and state that the aMwe information is
correct.L agree to comply with all city tt,d county ordinances and stoic law.neteting toPERMIT ISSUANCE MECIIANICALFF.F.
f^ building construction.aM hereby authorise representatives ofthiscity matter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH,
(We)agree to save.indemnify and keep harmless the City of Cupertino against
Iiabilities,juJgm 1s.GKta wd p«sesw 'chmayinatywaysecrue againetmid City AIR HANDLING UNIT(TO 10,00)CFM) S. VC)
or the mining tie pc t.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si m e ApplicanUContnc r D e EXHAUST I100D(W/DUCD PAID 2�� �y ••a��•�_
HAZARDOUS MATERIALS DISCLOSURE HEATING VNIT(TO 100,000 BTU) Date R�eceip,p�
Will the applicant orfuture building occupant store or handle hanrduus material HEATING UNIT(OVER 100,000 BTU) TOTAL:
tIJ
as located by the Cupertino Municipal Code,Chapter 9.12,and the Ilea di and Safety
Code,Sector,i ElYes 11 No 23532(a)p
❑ VENTILATION FAN(SINGLE RESID)
DA
BOILER-COMP(3HP OR 10),"BTU) IPUK(f, TE,
Will the'PP licanmrfuture huilJing«cupam useequipmem mJeviccs whichemit - f� 1 Y.I '
;anlaus air contaminants as defined by the Bay Am Air Quality Management
at mics? BOILER-COMP(OVF.R 100,000 BTU)
❑Yc» 0N NEWRESIIIENTIALMECH. SQ.FT. DEC 21 1993
I have read the hnnnlaus mmeriuls reyuiremnns under Chapter 6,95 of the
California lleahh&Safety Code,Sections 25505,25533 and 25534. I adersmnd that CITY Ur utJYCl111191J
if the huild'mg hoes nm currently have C tm
emt,,bat it is my responsihility to ramify the -
Occupant of tlm rcyuirementi which mull he mm prior m issuance of n Certifrom of
Occupancy.
t
Ov,va,mmohorrod agent' n Dara TOTAL: ISSUEDBY: