25586 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
fl LDIN(:-F,hF.2."1'R A PERMIT NO.
CITY OF CUPERTINO PLUMBING-MFCIIANICAL 25586.
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PNOd F.C'1'IUF VI'IFICATION
BUILDING ADDRESS: /� �/ r / `' (��(��/ SANITARY NO. APPLICATION SUBMITTAL DATE
22/ \ ` It, \ 1 LOT# q^,7_1_I1k3
OWNERS NAME: - PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROLX
I V-F_V_es-T, GI SS�xrL MtW•�a-L_ C.,� S3 D
\RCI11'IECTBSNGINEER: LICNO: A ' S:
vob -9X7
�a--606y 01 190ck) g-Lk_ Dv, ,
'ONTACT: PHONE: QTy ELECTRIC PERMIT FEE BUILDING PIT MIT INFO
MLQ PERMIT ISSUANCE BLDG ELECT PLUMB MIECII
aCUpRi
LICENSED CONTRACT'OR'S DECLARATION
APPLIANCES-RESIDENTIAL
OKZ I hereby affirm that l am licensed underpmvisionsof Chupter9(commeocingwith LOB DESCRIPTION
4100Section 700(dof Division 3oftbe amines,and Professions Coda,md my license is in PANELS a
< ❑Z, fall nsCad effect. UP'T02o0AMPS E1��
License e Cllass Lic.M
F<M Date Contmdor 201-1000 AMPS e 1 a A R $/SQ.F1'.
ZOyL ARCHITECTS DECLARATION OVER IB00 AMPS I l'
CZ-0 1 understand my plans shall he used as public records.
F Ful SIGNS ELECTRICAL.
Q j Licensed Professional
Ecd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C. - 2
p'OaU I hereby affirm that I am enempt from the Contractor's License Law for the of
tXi134ro following reason.(Section 7031.5,Business and Professions Cotte:Any city orcounty TEMP.METER OR POLE INST. TE w/�� •�
F-E,01 which reyuires a permit to roodmct,after,improve,demolish,or repair any,lonelme
.4 Y� prior I,its mur,,also reyuires lltoupplicam fit rsueh pemduo If lca,igned statement MWIIR DEVICES
�a�pz that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter SWIMMING POOL ELECTRIC VALUA
mmaLL 9(coramancing with Section TB11B)of IXOdon 3 ofthe Business and Professions Code)
lgil
,_,L .,,but he is esempl Nerefmmund the basis for the allcgedexeraphon.Any,mmimcif
I-.ZQ noSection 703 LS by any applicant for a permit subjects the applicant en
o a civil penalty of OUTLETS-SWITCHES-FIXTURES
t mom than five hundred dollars($500).
f=❑ NEW RESIDENTIAL ELI:CTt _SQ.FT. STORIES TYPE CONSTRUCT ION
K F_o ❑ LasownerofNepropeny,ormyemployaswimwagesastheiraole<ompemation,
a3= will do the work,and the structure is not intendedoroReud forsale(Sec.7IW4,Business
and Professions Code:The Contmeors License Law docs no,apply tr an owner of
property who builds or improves thereon and who does such work himsel f or through his
OCC GROUP RFS.UNITS
ownemployces,providedthal such improveramisare not imendedorofferedfusale.If,
however,the building or imprnen¢nt is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
colic.), QTY, PLUMBING PERMI I' FTiE
❑ Lae nwnerof the proreny.amenclusively connaning with liansedconwnors to FLOOD ZONE AVN
construct the project(Sec.IBM,Business and Professions Code:)The Contractor's
Liceaselawdeesnotapplytoan.amerofproperywh.builds rn improves thereon,end PERMIT ISSUANCE
whoccarrictsforsuchpmpi with acontraaorts)licensed Pursuant to the Contractors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this Man BACK FLOW PROTECT.DEVICE ? SIDE FEES
SANITARY Y N
Owner Dire DRAINS-FLOOR,ROOF,AREA,COND. RIECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihercny aflirm Nutlbuwueenificsite of wnsenun calf-Insnre,ora cerificam o[ TORES TRAP RIECI?IPIb
FIX
PARK FEE Y N
Workers'Compensation Insurance or a certified copy thercof(Sec.7HW.Lnb CJ which
covers all employees under this Knoll. GAS-EA.SYSTEM-1 INCA OUT RECEIPT X
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK RRilr.
❑ Cenifiedcopyishembyfuntished.
❑ Certified copy is filed with the city inspection division. GRP.ASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
p'hia scmimn need not he completed ifthe permit is fs-Ime hundred dollars($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m lean.
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENI'pE1.EC1'R
not employ any Person in any manner m hjen m the Workers PAID
rmpenaalront1�s�fC�MJom'vDate so ys,^M�m�Fy WATER SYSTEMTREATING Dale Receipt#
O Z ArMiCE `/ ,L S
CE TO APPLICA 1 .otter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
z become subject a the Workers Compemetion provisions of the labor Cade.you must BUILDING FEE
a > forthwith comply with such provisions or this permit shall be deemed revoked.
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ l hereby affirm that here is a construction lending agency for the performance of 6. ELECTRIC FEE
O the work lint which this permit is ixsled(See 3097,Ci,C.)
Leoder'.s Name PLUMBING FETE
0 F leadersnddrex, QTY. MECHANICAL PERMIT FEE
U I sem y that 1 have read this aPldiedio t and sate that the above information is MECHANICAL FEE
>" 1U coreat.I agree to comply with all city and county ordinances and state laws relating to FERMI'r ISSUANCE
F" building construction,and hereby amhoriu representatives of this city to enter upon Ne CONSTRUCTION TAX
U z chose-mentioned property for inspection purposes. ALTERORADDTOMECIL
Z (We)agree to save,indemnify and keep humless the City of Cupertino almost,
Iiabilities,judgmems,cmts andexpenses which may in any way accmeagaimt said City AIR HANDLING UNIT(TO ITW CFM)
in consequence of��the granting of this permit.
2"7^S3 AIR IANGLING UNIT(OVER 10.000CFM)
Slgnaiurcof Appli Date EXHAUST HOODOMMUCI) PAID N /
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) - Date Receipt p
Will the indicted or future building occupant store or handle hamdous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? V EI ILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicunmr forum building occupant esu equipmentor devices which emit
BOILER-COMP(3HP OR 100.(100 BTU)
humrdous air con amounts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dimnct'r
❑ p A B D
Yes ❑No NEW RESIDENTIALMECII. SQ.FT. '
1 have read the Safe,,
Code.
materials requirements under M.1mr 6.95 nd the SEP 27 1993
California have
a aflh read
a pity rdous Sections 25505,25533..d and 25534.I understand that
Edo,building does not curently have a,moot,that it is my respomibility to notify the s�..�
occupant of the acquirements which muss rte mel prior to issuance of a Certificate of /s try "" '-1'4 �V
Occupancy. V�11 Ctrl-Vve1 {//y,��/7
Owner n ambonzed agent Date TOTAL: ISSUED BY:
OFFICE