25093 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING—ELECI'll TCA. FERMff NO. 0
APPLICATION/PERMIT PLUMPING-MECHANIC A11
BUILDING ADDRESS
DIVISION -,BIRLIHNG PROJECT IDENTIFIGATIoN
BUILDINGADUNCSS: .�f 1,s /rye,,,s,'l/L� SANITARY NO. APPLICATION SUBMITTAL DATE
'2-0 {�..y („_yZQ_79/ UNIT. LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME. LIC NO: l
N/C CONI ROI M
f
• ARC IMC`/ENGINEER: LIC NO. ADDRESS y
CONTACT: n �yPHONE: QTY: ''A lase q CLERIC PERMIT "FEE -'BUILDING PERMIT ENI O
Z0—Sl�j} BLDG ELECT PLUMB MECH
PERMITISSUANCE' ❑ ❑ F�_ ❑
LICENSED CONTRAC'TOR'S DECLARAgJON APPLIANCES-RESIDENTIAL IGH DESCRIPTION
I herebyaffirm that l am licensed underprovieions ofatipter9(commencing with
000 Section]BBB)of Division 3 of the Business end Profession Code,and my Iimor se is in PANELS
aZF fill e0maeffect. 1 ., L 1
4 Z W Liters e Class Lic.# 69fML (�O 201-1000 AMPS V J
vE.t6ca Date c 's Conwctm
F
ZUK ARCHITECTS DECL ION OVER I"AMPS p S hg�'D�ORAgp�s,�� 1 $/SQ.FF
qC��Z-0 1 understand my plans shall be used m public records. II � g �1 II N
ICAL —
ga, Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. `� 1 1'�
Licensed Professional SIGNS
XO:ii I hereby affirm Nat 1 am exempt from the Contractors License Law for the
Wei u.y following reasin.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. �y
aJ O; which requires a permit no construct,elle,,improve,demolish,or repair any,Inoue p✓r
;!(N� prior m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
0 Nat he is licensed pursuant mthe provisions of the Contractor's License Law(Chapter
ea.a:
9(commencing with Seeion7000)ofDivision 3 ofthe Business aad Professions Code) SWIMMING POOL ELECTRIC VALUATION
W❑y or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-PIXTURFS
QSection 7031.5 by any applicant for a pemtit subjects the applicant to a civil Penalty of
0 not more than five hundred dolls,($500). NEW RFSIDCNTIAL HLELTR S .EI.
a3� C3I,mownerofihepropeny,ormyemployeeswirhwageseslheirsolecompenvdon. Q STORIES TYPE.CONSTRUCI'[ON
will do the work.and the structure is not intended moffered 094
for sale(Sec.] ,Business
and Profession,Code:The Contractor's License Law docs nor apply m an owner of
prnpcny who builds or improves thereon,and who does such work himxlf or through his
eroployma,pmvided thutsuch improvememsam not inteadetoroffined forsele.If. OCC.GROUP RIS.UNITS
however,the buddingor improvement is sold within one yearofcampleion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpox of
❑ I,sownendthe propeny,emexdmively conwaing with licenses contacmrstn QTY. PLUMBING PERMIT 'PEE IO.00D'Z.ONP. APN
consumer the project(Sec.]094,Business and Professions Code:)The Contactors
License Lawduesnotapply toan ownerofproperty who buildsarimprovesthereon,and PERMIT ISSUANCE
who comacm forsuch projects with a contractor(s)licensed pursuant onhe Contrast IC-12n I
ALTER (pA
License Law. ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this revson BACK FLOW PROTECT.DEVICE OM'SI . -E
SANITARY YN
Owner Date DRAINSPhOORRO(3F,ARG,COND. RECHIPT#
- ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihemby ul'finn thatlhuveecenifiwto o[wnsenua amifdnsum.or a certificate of RI3C1?IPT#
FIXTURS-PER MAP19
Wmker%Compensenion Insurance orecmifcd copythercogSaJSW,LebCJ which E -0� PARK IEE YN
rovers all employee's under this permit. GAS-EA.SYSTEM-I INC. OUTLETS RIiCF.IIT#
Policy# a'L - BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCI IECK Pliii
❑ Certified copy is hereby famished.
❑ Ceifedwpy is filed with the city inspection division. GREASF/INDUSTRL WASMINTCRCEPPOR GRADING FEE
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE TRAP SOILS PEE
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is for one hundred dollars($IW) SEWER-SANITARY-STORM EA.200FJ. ENERGY EP.
or less.)
I rectify that in the perfonrumce of the work for which this permit is issued,i shall WATER HEATER WNEWIE.LECIR
not employ any person in any manner air us to become subject to the Workers' PAID
Compensation lswsof Cfymie. Dere_ WATER SYS111EMITREATING Dam Receipt#
Q Applicant
z NOTICETOAPPLICANT:If,after making this Ce am of Exemption,you should NEWRESIDENTALPLMH. SQ.FP. TOTAL:
L r^7. become subject to the Worker's Compensation provisions of the Isbor Code,you must
L� > fonhwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
1 [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm Nat them is a conamuction lending agency for the performance of ec ,(
O the work for which this permit is issued(S .3091,Civ.C.) TOTAL: s et, ELECTRIC EE
lenders Name jA PLUMBING FEE -Q
W "1 I' - v
F 1<w Ic Address QTY. _ MI.CFIANICAL PERMIT -FBIi
V 1.I ag Out 1 have read this application and stem that the statee information is
Lia correct.I agrectocomply d wend tamomnd countyordinancesof and stem lawsr upon the PERMIT ISSUANCE MECHANICAL Ff:F.
_ Z hnildingcndonedtproert horuthonzp purposes,
vw ofihle city to enter upon the
V z ebnr(We)igree,propenyfornify inspection purposes. ALTER OR ADD TO MCCH. CON$'fRUCT10N TAX
(We)agree no cave,indemnify end keep may ms the City of most s against
incirmes,judg,ofhecosuundexpenseswhichmayinany way accrue egun,t said City AIR HANDLING UNIT(TO 10,0(10 CIM)
consequence of the gmming of this permit.
` AIR HANDLING UNIT(OVER IB,WO CPM)
Signature of Applicant,Contractor Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,0010 BTU) Date Receipt#
Willtheapplicantm future building occupantsoreor handle(exact materiel
as defined emi
by the Cupao Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVEN W,IXIO e'I'U) TOTAL: s DD
Code,Semi 532(ap
Yes F)No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,W0 RTU) ISSUANCE:DATE
Will the omountainou tus building bycocithe Bay equip men Quality
Management
�'k w 1 D
haindous air conmminane as defined by the Bey A.Au Quality Mangemem BOILER-COMP OVf:R Ilp,IX10 BTU r �Ii V
Dishier? COMP(OVER
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT, MAY 19 1993
1 have read the haaardous minimal,requirements it,Chirpier 6.95 of the
California Health&Safety Craft Sections 75505,25533 and 25534. 1 understand that
f the building does not currently have a tenant,than it is my responsibility to notify the '-CIj_y Ur.VU('G fI I IDV
cupumt of the m,faimntom,which most he met prior to issuance of a Cer iftcum of
Occupancy. qsr
Owneroraatumi,edagesn Date TOTAL: ISSUf:DBY:� Tr`u
I