25652 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO RITILDIS(7-ECL RI A. PFRMrr NO.
APPLICATION/PERMIT PLUMBING-MECHAMCAI. N� C C C
RUILDING DIVISION BUILDING PROJECT IDEN'TIFICAT']ON L J U J
BUILDING AD)RESS: SANITARY NO, APPLICATION SUBMITTAL DAI li
'V SKY 17%_2_93 UNIT# LOT#
OWNERS NAME: PHONE:PHONE: CONTRACTOR'S NAME: LIC NO: NIC l CONTHOLN '
RCHITECUENGINF,F-R: LIC NO: ADDRESS:
i l
VL_1,5, 5a
CONTACT: PHONE:: BUILDING PERMITINFO
QTY. ELECTRIC PERMIT FEE
BE ELECT' PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONI RACIOR'S DECLARATION APPLIANCES-RESIDENTIAL
]013 DESCRIPTION
QWz Iherebyaflirmlbml am licensed underprnvisionsofChapmr9(commencingwinh
�00 Seniors 20(p)of Division 3 oflhe Businessan�d.P��srofessions Code.andmy license is in PANELS /—
aVF- full forcCandeffect. S G4s"S I-(T UP T02(p AMPS Sk 1 , (-:s I
F I-W Llceme Cams Lic.p J L5 ^R
m<d ate — Commcmr 201-IBIp AMPS
ON/ ARCHITECTS DECLARATION OVER Has)AMPS
SQ.FT.FLOOR ARBA E/SQ.FT.
OZ
1 undcrslund my Plane shall he used us puM1llu tncords.
SIGNS ELECTRICAL
< w< License]Pnl
dessiona
w
w< OWNER Bempt from
m the CoATTON SPECIAL CIRCUR/MISC.
W1 hereby affirm Thal 1 am exempt from the Commences License Law for the
[1E R0< which following rcamn permit
raY(131S,Dusincs andimprove.
vefessions Code:Any city m mIcImy TEMP.METER OR POLF.INST.
F viO< which rcyulres n Pcnnif to cnn.aruut,nhcq impmvc.Jcmoli.h,ar repair any swnure
�O }-2 m m its issuince,irls., thea leant Bnsuch uo file asi dmiticmem POWER DEVICES
�ty Pri quires pP prsel 8La
C<Ou that he is licensed pursuant m the provisions of the Convectors License law(Chapter 6X�o Ir. 9(commenciag with Section70(at Division 3 of the Businessand Professions Code) SWIMMING POOL ELECTRIC VALU T
W_u, or that he is exempt hcrefrom and the basis for me alleged exemption.Any violation of OUTLETS-SWITCHES-Iq%TURES
y,G Sectio"2031.5 by any applicant for a permitubjects the applicant to a civil penalty of
W M of more than five hundred dollars(S$(p). NEW RESIDFi TIAL ELECTR _SQ.FL STORIES TYPE CUNSTRUCI'ION
��L n❑ Ldie wrk,and the
stucture myempinded ortM1wagesasidei(Sm.c0m.Business i3— will do diework,CasJO: strucommo is License La does of apply 2044.Business I
and ny%hions Code:TTe vesthecmr's License Lew Joca not apply to an owner of A A a ^ q C'^
pmpcnywyces,rsorimpmveslhimpmvnmentsu nsuintend oroffeor forstle.his
employees,provided that suchimprovcmenbarennlintendedoruffertdformle.If.
OCC.GRO RES.UNITS
however,the buildingor improvement is sold within one yearol complaion,the owner. TOTAL:
builder will have the harden if proving that he did not build or improve for purpose of ^
sale.). Q'fY. PLUMBING PERMIT FEE Z,
❑ Las owneruflM1epropeny.amendusivclycunvacning with licensed contractors to Il/) DNP APN
ommuct the project(Sec.2044,Business and Pmfeuiona Code)The Contractors — �
License Lawdoesamapply manowncrafpmpenywho builds or improves thereon,and PERMITISSUANCE I
who contracts forsuch projects with a contractors)licensed pursuant o the Contractors ALTER-DRAIN&VENT-WATER HEA) ARNP I
License 1,aw.
❑ 1 am exenrpl under gee. D&P C for 1M1is reason BACK FLOW PROTECT.DEVICE TSIUh FEF;S
SANITARY Y N
OwnerDate RECEIPT#
DRAINS-FLOOR,ROOI�.AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ ers reby Compenrmoalhave a rancecertificate of consent py themc(Secum,nr Lab C.)racofwhich FIXTURES-PER TRAY RECEIPTp
Wlrkers'Cnmpenution Insurance or ecertified copy thereof(Sec.3R(NI,Lab CJ which PARK I>lili Y N
rsall nn to cc's under thin I. ECEIPT'#
P Y pe^cat GAS INC.INC40UT'LETS BUILDING DIVISION 113H5
Policy N
Company GAS-G.SYSTEM-OVER 4(EA) PLANCIiIiCK FEE
❑ Cenified copy is M1crtby famished.
❑ Cenificd copy is fled with the city inspection division. GRFASF7INDUSTRL WASTE INTERCEPTO0. GRADING FEE
C17RTIFICATE OF EXEMPTION FROM WORKERS' GREASE FRAP SOILS Fill:.
COMPENSATION INSURANCE
(This sectiunrtmd nod becompliusi ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FIE ENERGY IEE
7or less.)
I cenifythat in the p afommnceofdre work for which Nis permit is issued,l shall WATER HEATER WNENT(ELECTR
not employ any persue in any ammm so as to become subject to the Workers' PAID
Compperimnlawsof Culifomm. Date WATER SYSTEM/IRPATING Date Receipt
C) Z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMIJ. SQ,FT. TOTAL:
F' y become subject the Worker's Compensation provisions of the labor Code.you mush BUILDING IEE
a - foMwith comply with such provisions or this permit shell bc decreed revoked.
451
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm than there is o construction lending agency for the performance of
U O the work for which this permit is issucJ(Set.3092.Civ.C.) TOTAL: ELECTRIC FTE
Lenders Name PLUMBING FEE
U" F leader's Add., QTY. MECHANICAL PERMIT FEE
U I certify that 1 have mad this application and same than the above information is MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and sate laws relating to PERMIT ISSUANCE
building construction,and hereby amhonce represcatrussofthis city menterupoodho CONSTRUCTION TAX
U above-mentioned property for lnspetion purposes. ALTER OR ADD TO MECIL
(We)ugrce m save,indemnify and keep harmless the City of Cupertino against
liabiliti gra xcostsandenpense "M1 nanywayaccmeagalasl.rad City AIR HANDLING UNIT(TO I(L"CFM]
mon. comes a,rooting of th' pe t 6
AIR HANDLING UNIT(OVER 10,000 CFM)
Saambae" Applicant/Confine Da EXHAUST HOOD(WMUC1) PAID
HAZARDG TERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt
Wi l the applicant or future building mecupam store or hmWle ha'uNous material HGTING UNIT(OVER 100, O BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Ihealth bard Safety
Coda Section 25532(a)2 VEN'1'IfAT10N FAN(SINGLE RESID)
❑Yea ❑ No
ISSUANCE DA'I'S
Will thea Iicuntorfummbuildin ecu nuscc entnrdeviceswhichemid BOIL17R-COMP(3HP OR I(At BTU)
PP g pan geaA
M1aradous air conl:uninanns ox defined by the Buy Area Air Quality Management ,OILER-COMP(OVER I W,000 BTU)
District? ❑ PAID
Yes ❑No NEW RP_SIDFNDAL MECH. SQ.FT.
I hove read the le radoas materials reyuiremcnrs under Chapter 6.95 of the OCT6]
Czllform.l lcahh&Safely Codc,Sections 25505.25533 and 25534.1 undermand tltm V! 2 O
if the building does not canemly have a fermnh Ihnt if is my responsibility m notify the
occupant of the requirements which all III,met Prim 10 issuance of a Cenaf rd,of
Occupancy. n'/~
Owner car awhomcd agent Data 'TOTAL: ISSUED Y. w
OFFICE