25771 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO bo_nj`°"`"""""^'` PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUnmlac.MecHanrcal. 25771
IXs_{^Tyeyt9,BUILDING PROJECT IDENTHICATION J1 1 / 1
BUILDI{N_GGAAA DRESS: /� n CAT_ NO APARZA`gTIIOONN'SUUS'gBMIM`IJTTALDA9
V S- A c4 i9.1� CA r UNIT# LOT# I` 1 I `/
OWNy1{S rNAC E�� �� QHON'-� I CONT0.ACfOR'S NA LIC NO
44_ L / N/C CONTROL
HUECTlENGINEER. LICNO AD SS: ❑
I
CONTACT PHONE: QTY..Xhtrt; ay '�ELECIRIC PEaRMI'C�'•�a'+.'N.i' �`'Y::•�r...:N`5 fit_-Ir'_';�Jbii BUILDING PERMIT INFO•"`.":.'!.e'
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I ❑ tr({
W LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL �� JOB DESCRIPTION
p00 IheZ4.'1fD=Lod a of the Business and tsmvoon&Cache,add(commencing with a``/ lw\ 1`��11•�FY,/jr'w'�'
00 Batton)0001 of Division J of the Busmeas and Profession Cade,and my Lttme u m PANELS
<ZW Lull fneeand effect.
y¢a Daienu chase con.actor o BBB AMPS
]Oy- ARCHITECpSDECLARAMON= OVER IOOOAMPS SQ FT FLOOR AREA $/SQ FT
OZ—o I undemund my plane shall be used aapublerecnd,
p to F ul SIGNS ELECTRICAL
QyMJ Leenscd Pmfnaonal
cdenxQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KCiV 1 hereby affirm that 1 am exempt from tire Contractors License Low for the
=�wEi following remon.(Second7 0315.Bustnese end Rofrsaion Code:Any city or counry TEMP,METER OR POLE MST. ,
which wgULM a permit to construct,alter,improve,demolish,or minor any struciata
iWY� pdonoivissmnc4,also rqumNe applicant for such peimnto file satirical statement POWER DEVICES
W z pC that he a Lcenxd parsuonuo the provcion of Ne Conrrwmh Wcense law(Chapatis SWIMMING POOL ELECTRIC
ajeeL• 4(commenang with Section 7m))ofOivieionJOfNeBmineas and Profevion Cade) VALUATION
ty_y aflod heis exempt therefrom and the basis for the allegM eaempuon.Any violation or
FZY Se[,,on]831.56Y any appLCwt fora peimn mbnecu the applabas m-civd penalty of OMETS-SWITCHES-FIXTURES f
m than five It added dollars""N"1 n �\ i1' ^ �' '•� r
C _ NEW RESIDENTIAL ELECfR _kQ.F i, ,STORIES 1r
wE .asowncro(thepmpcny,army employeeswM wegcaastheirsolecompeiwvon, I J 1'I�PE CONSTRUCf10`
L3— �Ilmothee work.and the structum unrtimendedorof(esd forsale(Sec.]004,Board as
d sons Cad Th e Cantmnore Lianas Low does not apply or en owner of
propenywhobuicismmpmvea Hereon,aMwhodwasithwoik himsel(orthrougn lass ` G L-_S' RES.UNITS
employeee,pdvided Nmsuchimprovemenuare natintended orof(emd fore a le.lf.
own however.the budding orimprnvemcm r Said within orayevofcamplanon,the owner. J.OTAL ` Q
budder will have the burden of pmvmg that he did not build or tmpmve far purpose of I 1 �A 1 C
sule.l. FE .,�...
❑ I.uow erofth ny.amexclusivel contrvetm withlicenu conwcwmto +� 8' PLUMBING PERMIT yy`� FEES:a't« FLOOD ZONE APN'
QTY. Iff'•„ iai �'.x7. � ,}r
e Pee. Y B w 'cu v a.:xsr...,,: a•usr :.4e,a^:.d,,,.•.
License the project(Sec.to an nero(pr per Professions Code:)The Convector's PERMIT ISSUANCE
Leensetrawdtorsuc PnecT uiah ricompropertywhobd!purrimpsoves Condon,and
License lavers loreuch proleas wnhaconvector(a)Iicenrd punuw sec tha Contracors ALTER-DRAM&VENT-WATER(EA)
who ry}�
^:FEE SUMMARY,•.;'.,:, ,u
El am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE .+' OUT SRA FEES .>
ISANITARY Y N
Owner ^ae 1 _ RFP_SIPra
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.AREA,COND SCHOOLTAX Y N
`�lherebyaffismthuIhaveacemftmwo fco ntwulf.mswe.orac=Ficateof FIXTURES-PER MAP I RFCFtpra
nrketi Compcnvuon Insurance or a cemfte!copy dimeof(Sed.38M.L ify C.)which IPARK FEE Y N
covers all employ«s under this Amnia ECEIPT X
Policya GAS-EA.SYSTEM.]INC.INC40IffLETS BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER 4(EA) IPLANCHECK FEE
❑ Cemfed copy is hereby(ainlshoL
❑ Cemfted copy is fled with the city mapecapn division. GREASE/1NDUSTRL WASTE INTERCEPTOR (GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP (SOILS FEE
COMPENSATION INSURANCE
(This action nod not be completd ifthe permit is for carte hudred dollare(S 1000 SEWER-SANITARY-STORM EA.200FT. (ENERGY FEE
or less.)
I comfy that in the performance of tire work for winch this permt is food,I Shall WATER HEATER W/VENT/ELECIR
not employ any Paton in any manger Sa aa to become subject to the Workcrs' PAID
z Campenetionlawsof Califomta. Da•- WATER SYSTEMIMHATING Data Reiceipta
Applicant
Z 0 NOTICETO APPLICANT:If,after making this CCdLfl=C of EaemPVOn.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL
✓n become subject to the Waster's Carommoon mAutions of hie Labor Code,you must
Y7 fonhwnh comply with such provisions or this Femur shall be deemed remi;d. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SI71SMIC FIX
I hereby alfmm Nat them u a twomucuon lending agency for the perfomance of TOTAL: ELECTRIC FEE
J Q the work for which Rua pernn r Issued(Sec.309].Civ.C.)
Laaddee Nun- 1ar:. E �y.r:ura»••.sslw:r.r...,end..•-
3• — QTY TMECHANICAL PERMIT.f+ "a" i p'FE6fs;� PLUMBING FEE
Lenders Adds-•• �,tp„"4) xe..::.wS.1a.'.Y.:tWY kV✓.\ia __ ___
1 crni that 1 have mad NiS epplicedan end smua Has die obove iidoistudm a ”-% r.. vwwsa•,,rot...
correci.l to wmply with all city and county oNinrcoand sera lewatelatingm I PERMIT ISSUANCE MECHANICAL FEE
_ rA RhC.,.ta.ction, emby euthonaerpmsenanvpof thiSnry wensttupon the Iffm
(, Z ed form non puryoxa I ALTERORADDTOMECH. CONSTRUCUON TAX
s <.im fy rd tap h laa tte�a City of Cupemno agumt
IN asnecax of tpens��NC11, .yin. antyaccrueogurutaaid Ciry r AIR HANDLING UNITfT0 IB.000 CFMl Q 1I!! � AIR HANDLING UNIT(OVER 10.00)CFMI
ppb scar me '/'IT IIOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 103.00)BTU) Q applicant orfuture building occupant store or handle hazardous mmenal IIEATINC UNIT(OVER Ip),BOU BTU)tihe Capemna Municipal Cda Chapter 9.12,wed the Health arul Safety
Code.Section 255J2(al^
13 Yo ❑No I VENTILATION FAN(SINGLC RESID)
❑
Willthedpplicantor l'wurc buddingwcupunmxegmpmenfmdeviceswhchemnl ( BOILER-COMP(JHPOR 10).N)0 BTU)
ISSUANCE DATE
�hazandous air conammuna as defnd by the Bay Asm Air Quality Management BOILER-COMP(OVER OILM BTU) T� Sal
JlNict!
❑Yes ❑No I I NEW RESIDENTIAL MECH SQ FT. NOV 17
1 have tea the hasvdou>mae ea mu
nals ruman under Chapter 695 of the I 1993
CJldama l health&Safety Cure,Sections 25505,25533 and 25534, (undemund thin
if he bwldmg dries not adrenal,have it mnent,Ihm nn my respormibdny to only Ne l I ".il ' °it •,I;F"CT'I II'IV
ccop.mt nl the rcgmrcmcms which mini be me,pn n w rswence of a Ccniftcaie of
fMCUpaacy _ __
Ower n ar uwhunzed Agent Uate �"1'.RI�� IISSUED BY
OFFICE