25186 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOB R,DI 1:-ELECTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMB NG-MECHANICAL 25186
WILDING DIVISION IID I LDINO PRO.IRC'I'IDF.N'TIFICATION
BUIL. NO ADDRESS: SANHARYNO. APPLICA'I/[ON SUBMI'I.1'AL DA'HE
EQLwCdQ UNIT# LOTH
OW fiRS N MF.: PHONE: CONTRACIORS NAME: LIC NO: law
W Ca `A I N ell1
•
ARCH]'I'E /EJG Elift: LIC NO: 0S.
3 l, G L l
CO ACT: P110 Q y e
Jll er-C fA Cbh-LLS 91 `2 1 OB IS ELECTRIC PERMIT FEE HULLOING PERMIT INFO
Bs PLUME
E
PERMIT ISSUANCE � '��
LICENSED CONTRACT'OR'S DECLARATION I
APPLIANCES-RESIDE L JOB DESCRIPTION
psZ I hembyaffrmthat lam lianxd underprovisims ofChapter9(commencing with
POO Section]f1110)mf Division 3 ofthe Busines.and Professions Code,and my license is in PANELS VA I� /{/t�r�{��7 �'��\�\�
yy'ds full force and effect.. 1 7o POO",O , • � �•
_zW Licence��"rrrrrr===����Lic.It ` UP T021NIAis
ysc,z Date Comrenar 201-Iq A PS
1-'. ` _ , ARCHITECTS DECLARATION SQ.Ff.FLOOR AREA 3/SQ.F1',
ZOz-M I understand my plans shall be used as public records. OVER AMPS
P:44 ELL TR A.
JLicense]Professional
99966 OWNER-BUILDER DECLARATIONPECIA SC.
O'U 1 hereby affirm that I am exempt front the Contrenors License law, th
cal following rI...(Section 7031.5,Business and Professions Code:Any city m cra` TEMP. H R PO -INST.
pl which requires.pennta,,mowct,.Imnts sa
r.improve.deal ish,or repair any tructure
priortoit,issuance.0Borequirestheupplicamforsuchpemtitmfile.signeda.¢m-at POWER VICES
�Om 9(comisncing with Section
")of ivisimf the Comrucmr's Licensees.ons C.1.)
a6M, md.h I,iotewith Secfiner it
)he Division Sof Ne Businessand Professions Code) SWIMMINGP LF.LISC'1'RIC /�� VALUATI/OSN
ty�a onhat he isexempnhercfrnm and the basis for the alleged exemption.Any violetianof UTI EL'S- ITCIIfS-PIXTIIRCS
F T
Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty of Ls ���rIII U cep
not more lM1un rise hundred dollars($SfIO). NEW RE. PNTIAL P.LECI'R _SQ.FT.
m ❑do
wncrnftd t pmpcny,nrmyempinded withwed forstheirsee 7t ,BAnt,, S'fORll?S TYPE.CONS FRUITION
d will do Newons andthe he Coeisnotiaticense Law
notl apply to an,Business
and Professions Code:The Contractor's License Law Jces not apply m an owner of
property who builds or Impasses thereon,and who does such work hineselfor through his OCC GROUP RLS.UNITS
oweemployees,provided that such improvcmear are not intendedoroffered torsade.IL
however,the building or improvement is sold within one ye.rofcompletion,the owner. A
builder will have the burden of proving that he did not build or improve lin purpose of
salcJ.
❑ I,mownerofthepmpenyamexclusivelyconv tingwithiimpsalconunctorsm QTY.�> PLUMBING PER T PEE FLOOD ZONE APN
consumer rhe project(Sec.]40,14,Business and Professions;Cade)The t t RM 't!S E
License Lawdoes not apply to an ownerof pmpeny who huilds m improve . ,
whoenn0uue[arsuehpr�jeet�with.eontrucmr(s)lieensalpursuantmth ¢cors
License Law. jr! /"\ 1) A M(JA) FEE SUMMARY
❑ l or exempt under Sec. ,B&P C fo`hy`6 )
-� V CK OT -V E SANITARY OUTY . FS N
Owner Date _ RECI?IPI'k
P,AREA.CO D,
WORKMAN COMPENSATION DECLARATIO SCHOOL TAX YN
❑ Iherahy vfllrm thnllhuveoaNfieme of consun nt adf-immueenlficvte of RECI?IPI'a
pens. FlXTURES-PER TRAP
.' Workcrs'Com tion Imuran.orvartifcJ wpy Ncrenf(Sec.JgBB,1ab CJwhich PARK FEB YN
rs ell employee'.under this permit. GAS-EA.SYSTEM-1 INC.40 . S RE .IPI'.
Polcya Bl DWG DIVISION F.I:S
Company GAS-EA.SYSTEM-OVER�A) PLANCHEC
❑ CerifcJcopyisherchyfumished.
❑ Certified copy is filed wiNthe city inspection division. GREASIVINDUSTRL 10STE INTERCEPTOR GR I ? i�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP pILAVEE �a
COMPENSATION INSURANCE
(This section need not becompimed iftbe permit is tomon,hundred dollars($100) SEWER. NFTARY-STORM EA,2)(t ENERGY FEE
or less)
I cert fy thppti the performance of Ne work for which this permit is issued,Is WA' HEATER W/VENT/ELECTR
not em Loy arrj rso any m m m beco au at m the W PAID
Ce .,I w f t_ an cr so ars ATER SYSTEM/TREATING Date Rcceipta
QO
Nil APPLI If.after tking this Cerficale mf F.semptio , oashould NEWRESIDENTIALPI.MB. SQ.Ff. TOTAL:
(/] hecnmc suhkct to the Wo er'sC nsminn provisions of the Lahr ,you must
5 forthwith comply with such prov'i ser this permit shell be domedV'remenceof
ed. BUILDING FI21?
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE Q
V z I hereby affect that there is armistraction lending agency for the
the work for which this permit is issued(Sec.3(No,Civ.C.) TOTAL: ELFC TUC PIP
Leader.Name
QLender's Address QTY.- ' MECHANICALPERMIT FEE' PLUMBING THE
V I certify that 1 have rtud this application and stem that the above information is
.-�"' 0. carat I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE. MECHANICAL ME
building construction,and hereby a thoriu representativesoflhiscity to enter upon the CONSTRUCTION TAX
V Z above-mmoJoned property for inspecron purposes. ALTER OR ADD TO MECH.
(We)itace ro save,indemnify and keep harmless the City of Cupertino against
Hifleitice.judgmems,costs and expenses which may in any wayacrneugiimt said City AIR HANDLING UNIT(TO 10,"CFM)
I.rmaob amrce ft granting ofthis permit.
("��' AIR HANDLING UNIT(OVER IO.IXNI CFM)
mum
urAj7p JOhnocom mr Data EXHAUST HOOD(W/DUCT)
PAID (7
HADOUSMATERTALSDISCLOSU HEATINGIINIT(TOIN,"BTU) Dm aNeceiptaC
Willthcapplicant rfumm building occupant store intent ehaurdousmaterial
as defined by the Cupertino Municipal Cnle,Chapter 9.12,end the Heahh and Safety HEATING UNIT(OVER IW.IlW BTU) TOTAL:
Coda Seainn 2.5532(u)1 VENTILATION FAN(SINGLE R tSID)
❑Yes ❑No
Will N<appliwnmr it,,..building occupant use equipment or devices which emit
BOILER-COMP CHP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as dented by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) p!k
JisrticC! - t
❑Yes IJ No NEW RESIDENTIAL MECII. SQ.FT.
I have read the hurnrdous materiall requirements under Chapter 6.95 of the
Emitted.Health&Safmy Code,Sections 25505,25533 and 25531. 1 understand Nat J W��
if the building does not currently have a tenant,that it is my responsibility to notify the
ocupnnl of Lha requirements which must he met prior to issuance of.Cenifeme of I+ ,I til 1
ece'rey. - GIIr
Owner or nmhorizW.gem Date ISSUED BY: VU
I Q