25925 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO URaNc-EE CIlA PCA. PERMITNO.
APPLICATION/PERMIT PIN(;PRUMB NO-MII)F1ASIFI(: X925
HUII,UING DIVISION IIUILDINf,PRO.IECT IIIN:NTIFIf,ATII/M1' L J G J
INWILDINGADDRESS - SANITARY NO. AIPLICA�ON SU1 All;
76� 9�(6r m�aN�c a�ajlor►a OVO ora 2 6
G Job Y1AG.1 o�CTOC/-�rre r0' q96-io r.' ACTOR'S NAME: LIC NO:
N/C CONTROL#
RCHITECTpiNGINEER: LIC NO: DDRESS: Q�� /� A ❑
r-oN'I'ACI': PHONE: QT<Y��t- ELE/CT`YIBI7C)NEL MIT" FEE BUILDING PERMIT INFO
.BLDG ELECT PLUMB MF,CH
PERMIT ISSUANCE 0
El jt
LICENSED CONTRACTOR:S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRI ION
. Dyg Thereby of i NeG 3 of the
Business provislmnsions Code,and
my Beene with
�s100 Section]UMI).!Division J of the Business and Pmfessiom Cale,and my license is in PANELS
C,IF-.. full force and effect.
F y E Licrnsc Class Lim.p UP TO 200 AMPS
m?y Date Cmmmctm 201-IOOOAMPS SQ.IT.FLOOR AREA $6Q.FT.
ZONZ ARCHITECTS DECLARATION OVER 1000 AMIn
0z_= I understand my plans shall Ix used as public records.
F h F til SIGNS ELECTRICAL
< Lneread Professional
�ya'2 OWNIiR-HUIIAF.R DECLARATION SPECIAL CIRCUIT/MISC.
�ax Oc. 1 hereby affirm Dal I am exempt from the Contractor's License Law for the
W 3 u 1y< following rmson.(Section 7031.5,Business and Professions Code:Any eiryor county TEMP.MITER OR POLE INST.
0J which requires a pemril 1.constmct,almq improve,Demolish,re repair any stractam
N$ prior to its issuance.also requires the applicant!orsach permit to file asigned statement POWER DEVICES
W K p that he is licensed pursuant the provisions of the Concurs License Lew(Chapter SWIMMING POOL ELECTRIC
m oat' 9(commencing with Section WRS)of Division 3 ofihe Bmi ness artVALUATIONCCNe) VALUATION
yYj_us or that he is exempt therefrom and the basis for the alleged exempllmc Any violvtionof OUTLETS-SWITCHES-FIXTURES
FZa Section 7031.5 by any applicant for a permit subjects the applic......ivil penalty of
< rvthan fvc hundned do)lure S5(m). NEW RESIDENTIAL ELECTR SQ.FT. STORIES l'YPE CONSTRUCTION
Wt L asowncfofthcpropeny,ormymiploymswithwagesutheirmlecompmsation,
W 3 III Jo lhewmk.anJ the svumum isnot intended proffered formic(Sec.7o44,Business
Professions Coale:The Connector's License Low does not apply ro an owner of
P
y who builcismimprovesthemon,aadwhodo ssuchworli himselforthenughhls
moom
emen oyccaprovidcd that such impmvcmentsmanot imm�dedoroffered fmaale.If. OCC GROUP RES.UNITS
however,the bdddmgpr improvement is cold wahin one yearof completion,theowner-
OTAL:
builder will have the burden of proving that he did not buil)or improve for pury.0 of -
sale.). QTY. PLUMBING PERMIT FEE MOOD ZONE APN
❑ I,asuwncr nfthc progeny,ten exclusively contracting with licensed conrs
uacmto
comawe,the Project(Sec.7014,Business and Professions Cade)The Centracmr's
License Lowdeesnot apply tuannwnerofpmperty whobmidis orimproves dation.and PERMIT ISSUANCE
who contracts for such nmjems with aamlracter s)licensed parammnp the Cmntrzclnr'a �a-nf(��1p�``�•-\•
License Law. ACfER-DRAIN&VFM-WAl'EH EA) eL FEE SUMMARY
❑ 1 am exempt under gcc. B&P C for this mason BACK FLOW PROTECT.DEVICE ,( I�y//a•Y , h
Owrter Dam L.., _ -
ANII'ARY 7 \ Y N
DRAINS-FLOOR,ROOF,AREA,COND. R RECEIPT 0
WORKMAN COMPENSATION DECLARATION SCHEK)L TAX �, •sY N
❑ l hereby affimt thin l have acmificme ofconunr loself-insure,maccoircem of FlXTURES-PER TRAP \ IPI#
Worker Cnmpenmtiminsumneeoracenifi<dcopythemof(Sec.380H.Lab C.)which a PARK FEE - V \ sN
era all employee's under this permit. GAS-EA.SYSTF-M.I INC.4 OITTLETS p �\ p RECEIPT#
Policy# 1 - \\ T� 1 GDIVISION ItiES
Company GAS-EA.SYSTEM-OVER 4(EA) ti PLA KFE
❑ Certified copy is thereby furnished. (�
❑ CcnilicJ copy is fled with the city inspection division. GREASMNDUSTRL WASTE INTERCEPT OR GRAD
CERTIIICATEOFEXEMPTION FROM WORKERS' GREASE TRAP P OILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundresddpllars(SIM) SEWER-SANITARY-STORM EA.200FT. �% ENERGYMM
or less.)
I certify that to the pe,f.mns.of the work(.,which this permit is icand,l shall WATER BEATER WIVENI'4SLECTR
not employ any person in any issuance so u m become subject to Ne Workers' PAID
Cmr,m.ma La rdf Celifomia. Data WATER SYSTEM/TREATING Data R ecipr a
Q Z Apphcaat
z � NOTICE TO APPLICANT:If,after making this Cenificate of Exempfoa.you should NEW RESIDENTIAL PLMFU SQ.FT. TOTAL:
� bac.me subject ce the Worker's Compensation pervisioas.f the Lhm Code,you must
� > fathwith comply with such pa,isinns.,,his patent shall be deemed revoked. ^ BUILDING I'F;E
137 Q SEISMIC FF:E
0. CONSTRUCTION LENDING AGENCY
Uz Iherebyalfmmis Peritisisued(Sm.a97.Cisagency for performance of TT /r— ELECTRIC ME
U O she wink for which this permit is issued(Sec:309].Civ.C.)
W r Under',Nome PLUMBING FEE
.`� Lenders Address QTY,?'"+ MECHANICAL PERMIT FEE
U I certify Nat 1 have head this application and sate that the above information is - . I - MECHANICAL FEE
come[,l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
buildingconstruclion,and hereby authorise representativesof this city t.enter upon the CONSTRUCTION TAX
U Z #have-mentioned property for inspection puryose_s. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and kap hwmless Ne City of Cupertino against
Imbiline 'udgmcnts,costs and serwhichmayinanywaylotmeaga.t.`i AIR HANDLING UNIT(1010,0W CFM)
enee of th gmndn f t. fiat`
ALR HANDLING UNIT(OVER IUIN1f1 CFM)
sign:V
a of ApplicaMConuaanr Da EXI IAUST HOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE I HEATING UNIT(TO I W.Ws)BTU) Data Rmcipla
Will the applicant or future building vm,.MI smut or handle incursions material TOTAL
as defined by the Cattleman Municipal Ctsd<,Chapter 9A2,end the Hashh and Safety HEATING UNIT(OVER 100,000 BTU)
Coda Section 25532(x)'1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑N.
ISSUANCE DAT
Will thea licanl or future buildin trice of mens mdevices whichemil BOILER-COMP(31IP OR 100,M)BTU)
PP l by he
4 P
hamrdom air rnnuminanm as defined by the Rey Arm Air QYWIry Management BOILER-COMP(OVER IW,000 BTU)
Di13riclr PAID.—SQ.Ycs El No NEW RESIDENTIAL.MF.C)IFT.
I have read the I.n,ardo.,mmerials nyairements under Chapter 6.95.f the FEB 151994
California)health&Safety Code.Sections 25505,25533 uad 25534,I understand Nat
if the building does not currently have a lesions,that it is my responsibility to notify the
o.mcal of the requirements which muq he mel He,to issuance of a CeniReate ofli IVU
Occupancy. C11y UI VIIFrr t
Discolor awh.ri.d agent Data TO'T'AL: ISSUED BY:
OFFICE