25000 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOu¢mNU-KL 'A'
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION IIUILIIING PROJECT IDEN'I'IFICkI'ION
PERMIT NO. 25000
BUILDING ADDRESS: - �
Sj `Z IO LOT'#
SANITARY NO.
APPLICATION SUBBITATE
ITAA.rL(iDDA
��2`+ {/
OVIZS1 Ahh /11 /� � � . `.� PHONE:
CON�CTpIl;.S N_ AyV ,/� LIC NO:
N/C
❑
CONTROL
g41M,(�.F{1w�,
(J' ,�,F��,L/.•
IARCHITECLIENGINEER: LIC NO:
ADDRESS:
CONTACT PHONE:
'
QTY. ELECTRIC PERMIT PF:E
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE
11 ❑
LICENSED CONTRACTORS DECLARATION
hereby affirm that l am licensed under provisions of asider 9 (commencing with
ScglAn 900) of Division 3 of Na lushest and Professions Code, andmy license is In
fall
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
nse Claaeffen.
Liana Class Lic.N
UP T02m AMPS
Uute Cannot
201 - Ilhm AMT'S '-
-
ARCHITLCT'SDECLARATIONOVER
I understand my plane shall he tomas public moods.
ILmm AMT'S
SQ. FT. FLOOR AREA
IN
S/SQ. FI'.
SIGNS ELECTRICAL
PA A
Licensed i'rofeuional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm Out I am aempl from the Contractor's Law for the
TEMP. METER OR POhP.INST.
Code: Any city or county
e: Any
followTER
whichinguim%afSma toconstruBusinasandve,dmoli
,do,t require.n permit m eo ca,lis, alter. imprava, Aemaraush nu or repair ed smsmre
pat censed(,alsond tprvisios of statement
��
POWER DEVICES
heir to th the Contractors Liease La
that he is licensed with Sectio m the provisions of the the Bmiare, License Law (Chapter
9 (commenting with Secoon]m0)nf Division 3nflM1e Business 0 Rofcsriona Code)
SWIMMING POOL ELECTRIC
__ TION
or that heisexemptherefrom and lhebasisfanhealleged"emption. Any violationof
Section ]031.5 by nny applicant fora permit subjects the applicant too civil unity of
Of1TlfT5-SWITCHPS-FIX'IVRFS
nn ore than five, hundred rtollarmyem).
ownerofthe , winthwagsas ion.
NEW RISIDEN HAL ILECIR SQ, FT.
STORIES
TYPE CONSTRUCTION
Neurals 044, Business
a mneo e is not imeral
11 dolhewons and the
nor
License La doncd es
d tmcmr s License Law docs not apply m an owner of
he Contractor's
Code The apply to an owner
-
e f�y who improves
mp[ny whobuilJsor improves thempnsand
mem,does such workhi affererovough his
not Eearomennrofferc, for sole.
however,
OCC. GROUP
RIS. UNITS
TOTAL:
-
thebuildivi or improvement
menti sold within ft owner-
milde, r.Ihe b,e hag ardled of dvmgthat he didn oneyat buil ro impro a f.. toe ireof
builder will have the buMen of proving that he did nm build or improve for porpoise of
'
QTY. PLUMBING PERMIT 1718
xlcJ.
❑ Las uwnernflhepropcny.amexdusivdycnnwning wiN licensed convacmrsm
FLOOD "l,ONI?
AI'N
instruct the project (Sec. 7044, Business and professions Cale:)'Dm Contractor's-
License Law does not apply toart owner ofpropcny who builds or improves thercon, and
-
PERMIT' ISSUANCE
who contracts for such projects with u contmctodid licensed pursmtn to the Contractors
License Law.
ALTER - DRAIN & VENT - WATER EiA)
ME SUMMARY
❑ 1 am exempt under Sec. , B & P C for this mason
RACK FLOW PROTECT. DEVICE.
SIDE P .E
SANITARY Y N
RECEIPTp
Owner' Date
DRAINS- FLOOR, ROOF, AREA, COND.
-
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑Thereby aflltm thio lhuveu<mificutc of amsenun sdf-insum, oracenifmm of
Warkcrs'Compensmionlnsumncem cenifeJ copy @e¢of (See. Jtl00. Lob CJ which
f7XTURFS-I'13R TRAP
RECIi11TN
PARK THE V N
covers all em la cc's uncertain Imnn' t.
p Y
Policy #
RECHIPT N
GAS-FA.SYSTEM-1 INC.40V1'LIi I'S
BUILDING DIVISION FEES
Company
GAS - PA. SYSTEM -OVER 4 (EA)
PLANCFIHCK FEE
❑ Certified copy is hereby famished.
GREASUINDUSTRI. WAS] It 1NTINCEMOR
GRADING FEE
❑ Certified copy ie ElcJ with the city inspection division
C17RTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMP12NSATION INSURANCE
SEWER - SANITARY - STORM EA. 200feL
ENERGY FEE
(This section need not becomplcted iftbe permit is forms hundred dollars($IN)
or J
WATER HEATER W/VENI'/FLECI'R
I cenlfythm in the perfamvmeofthc work far which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers'
PAID
WATERSYSHNIfFRFATING
Compensation Lnwsaf Califrom Date
Dam Receipt#
Applicant
NOTICE TO APPLICANT If, after tusking this Cmiticute of Exemption. you should
NEW RESIDENTIAL PLMIL SQ. FT.
'TOTAL:
became mbjecna the Workers CompensalFom provisi,m of the labor Code, you must
forthwith comply with such provisions or this permit shnil be deemed revoked.
BUILDING LEI?
SISSMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then Fs n corewction lending agency far the performance of
the work for wM1'mh this pemlit is issue) (Sm. 3119], Civ. C.)
TOTAL:
ELECTRIC FEE
Lenders Nome
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MIiC1FANICAI. 1'I?C
1 rectify toot 1 bO,. read Ilia application and state Ibat Ne above information Is
correct. lagrce mcomply with ell city and county otdinancu end nam lows rtlating to
1'FRMITISSUANCH 19
mildingconstru.tion, anJ herehy nuthmize represrnmtives of this city to enter upon the
above-mentioned propeny for inspection purposes.
ALTAR OR ADD TO MSCIL
CONSTRUCTION TAX
(Wc) agree to save, indemnify and keep hanNess the City of Cupertino against
haddlities,judg,jrnas and eapcnses which may in any wayaccrueaguinsl said City
AIR HANDLING UNIT (TO 10,000 CFM)
Cf
yucn egroming of this pertni
AIR HANDLING UNIT (OVER 10,00 CFM)
EXHAUST HOOD(W/DUCf)
PAID
a
. gnamm of Applican un tarm
/L
HEATING UNIT (TO 100.01011M) N
HAZARDOUS MA'I'Ek1ALS DISCLOSURE T
Date Receipt p
Will the applicant or future building occupem smmor handle ht/da dour maid
nx JcfineA by the Cupertino Municipal Cade. Chapter 9.12..6 the lleath and Safety
TO
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
Cade, Section 2S532hm?
❑ Yes ❑ No
BOILER - COMP YHP OR 100,00(1 BTU)
ISSUANCE DATE
Will theapplicandnftmre buildinguccuWm uxeyuipmem ordevitts which emit
BOILER- COMP (OVER 100,000 BTU)
hamrdous air contaminants as defined by the Bay Aron Air Quality Management
'
P
PAID
D
'Disn❑E)lel? _ Yes No
NEW REI?Mf1
SIDAf. M[CII. SQ. F1'.
1 have read the harmdaus materials requimments under Chapter 6.95 of the
Culifamin Health & Safety Cods, Sections 25505.25533 and 255]4. 1 understand that
APR 26 1993
if the building does not currently have u tenant, that it is my responsibility m notify the
.up., of the acquirements which must be met prior m isxance ofd Certificate of
C� iV
ay.
GUrCHO
ISSUEDBY:
Owvom, ner or uutbomcd agent Data
OFFICE