25897APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO:D1SirF.EECTRTCA'.
APPLICATION/PERMIT PLUMBING-NIECHANICA I.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERND'r NO.
25897 O 7
J o I
BUILDING ANDRESS:
'I fit 2 Lr-- DR Cu ���„�NO �i4 LTJ �
SANITARY NO.
APPLICATION SUBMITTAL DATE
2 -$-q�
WN' DIO E:
CONTRACTORSN LIC NO:
NIC
❑
CONTROLk
logSNAME:
n V �q
�RC 'CI' ENGIN SER: LIC O:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDGELECT PLOB M❑CH
WU YMN -
PERMITISSUANCE
LICFNSF-DCONTRACfOR;S DFCLARAION
ihatl amlicensed under provisionsofCheoade, (co mmencing with
Section rob, of Division 3 e lace Business and Professions Cade, and my linen, is in
APPLIANCES - RESIDENTIAL
PANELS
JOBDESCRIPTION1M17000)ofDi
full force it effect.
Li cense Class Lic.#
UPT0200AMTS
201 - 1000 AMPS
Date Corina mr
ARCHITECTS DECLARATION
1 understand my plans Shall be used az public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FL
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUR/M1iISC.
I hereby affirm that I am exempt from the Conwamo Linen, Lew the
TEMP. METER OR POLE MST.
co
Professions Cool Any city or county
iequires a(Seaian?03LSct,altr,
lend
whichrepair ed swemrc
which requires n permit to construct, alma improve, demolish, file LW s(atanrnr
it due applicant for succours i
POWER DEVICES
that ha licensedaal,refto the License
the provisions of the Contractors Licrnx Lawns Coder
that m is licensed #urs Section
Y(cammrencing with Section T000)of Division3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
or that he is exempt thereliom and the basis for the alleged exemption. Any violation of
Section 0031.5 by any applicant for apcmut subjects the epDlicavuo ecivil penahy of
t, �nVALUATION
�V� �i
(/ 0
OUTLETS - SWITCHES - FIXTURES
not mom than five hundred dollars (5500).
❑ I, asownero(thepmperry, ormycmployeeswithwagesaztheis soacompenuma
NEWRFSIDENTIALELECTR _SQ.FT.
STORIES
TYPF.CONSTRUCION
a
will do the work, and the sundries s nm intended reoffered for sale (Set. 9f 44, B usi nese
and Rofessinns Code: The Convectors License Law does not apply to an owner of
propertywhobuild5orimproves th ncer.rand whodressuchwork hint,lfor through his
employees,providedthatsuchimprovemenasaenmintendedorofferedfoeeale. If.
T
1
I L' a , RO e, T:�Y
h R UNIT
r r3
however, the building or improvement issold within me year rfcompleion, the owner-
builder will have the burden of proving that he did not build or improve for puryose of
r 1 n
a F% J
sale')'
❑ I, as ownerofthe property, arc endusively convading with licensed contractors to
instruct the project (Sec. 9044, Business and Rofessions Coda) The Cunneen,'s
License Law does not apply loan owncrefprs arty whtibuildsorimprovu diarrearand
QTY. PLUMBING PERMIT FEE
R'L0
TE
ApN
PERMIT ISSUANCE.
who contracts forsuch pmjwlS with a contsacmrfs) licensed pursuaeto ted Contncmr's
License Law.
pLTFR- DRAINfl VFM-WATER EA
f )
FEE SUMMARY
❑ I am nxcmpt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEE.
SANITARY YN
RECEIPT
0., Dam
DRAINS- FLOOR. ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
'❑ lhcmhy:ffimthutlhaveacen ifcate of consent to self -insure, or a certificate of
Wolters' Cnmpenzation Insurance ora comfied copy dwoof(Sec. 384, Lab C.) which
covers all employce i under this permit
Policy B
FlXTURGS - PER TRAP
RECEIPTN
PARK FEE Y N
RECEIPT #
GAS - PA. SYSTEM-] INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS -EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEB Lto JCL lit,
❑ Certified copy is hereby famished.
GREASR9NDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is fled with deciry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20l
ENERGY ME
OBas,ctionmed not be completed if Ne Permit is fofone hundred dollars ($100)
or less.)
WATER HEATER WNENT/ELECTR
I certify that in the performance of the work for which this permit is issued, l shall
so
not employ any person in any m az to become subject to the Workers'
PAID
Comppmsaionlawsof Caffomin. Date
WATER SYSTEMlFTING
Data Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIU SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of The Labor Code, you must
frMwith crmphy will such Provisions .,,his pcmdt shall be decided revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 herchy of Ener that them is a waauuction lending agency for the performun a of
the work for which this per it is issued (Sec. 3091, Civ. C.)
TOTAL
ELRCI RIC FTE
QTY. MECHANICAL PERMIT FEE
PLUMBING FTSE
Undei s Name
Lenders Address
I certify that 1 have read this application and same that the above information is
erect. Iagree to comply with all city Said county ordinances and state laws relating To
PERMIT ISSUANCE
MECHANICAL. FEE
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
building construction. and hereby amhmize representatives of this city to enter upon The
above-mcminned property for inspection purposes.
AIR HANDLING UNIT (TO 10,000 CFM)
(We) agree m save, Indemnify and keep harmless the City of Cupertinr against
Bud, 1ities,juof It co stsandexpenseswhich may in any way accrue against said City
AIR HANDLING UNIT (OVER 10.000 CFM)
in c�so��ppp.��cppp��a o e grnnti Ni t.
`/F�
EXHAUST' 1 IOOD(W/DUCr)
PAID
S' anteof AWliaanU vaco Tut e
HEATING UNIT (TO 100,000 HTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
HEAI'[NO UNIT (OVER I00,TNNI BTU)
TOTAL
W ill de mpplicaro nr future building rccvpunt store rf handle hamrnor, mr¢rlal
ex defined by the Cupertino Municipal Code, Chapter 9.12, and the I cahb and Safety
VENTILATION PAN (SINGLE RISID)
Cade. Section 23532(a)?
❑ Yes ❑ No
ISSUANCE DATE
Wi11 TM1eapplicanmr(erre buildingoceupamuae equipmenmrdevieeswhichemit
air contaminants az defrost by the Bay A— Air Quality Management
BOILER - COMP (311P OR 100.(g0 BTU)
BOILER - COMP (OVER 100,000 BTU)
D e -
• ^' D
'haeaedous
Jisnict?
NEW RIiSIDENTIAI. MECH.—SQ. Fr.
❑ Yea ❑ No
I have read the hazvdons materials requirements under Chapter 6.95 of the
FEB = 8 1994
California Health & Safety Code. Sections 25505, 25533 and 25534. I understand drat
if the building ares not currently have a learnt, that it is my responsibility to notify the
CO Ur
xcupam of the requirements whish must be mer prior m issuance rf a Cenificae of
VV
Vp
Occupancy./=1-!
aU(�r�C�ll\/
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE