25149 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINOLD>RG-67-EETR PERMITNO. 25149
BUILDING DIVISION APPLICATION/PERPLU
MIT - MBING-MECHANICAL
.BUILDINGPROJECT]DEN'TIFICA'1']ON,'•
BUILDING ADDRESS: /+y8`l!' SANITARY NO. APPLICAIIONSUBMOG
TALDAT
0z Is, V O` A v UNIT p LO'T#
O S NA PHONE: CON OR'S NAME: IC NO:
�CYr7ti/ dK4 6- T /vE 0 (3 1
N/C COMROLp
RCHITRCDENIIIEER: LIC NO:
CON'1'ACf: PHONE: 2T - up rn d K+R rg'3'4„i y y t i,x#d';. y
�,,. ` .� ���_O,a/ QTY. EL'ECTRIC PERMIT. I'EE" * BUILDING PCRtvfl'f INFO
/F•�ae T/ I4 w :' FX P U MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL ► JOB DESCRIPTION
qyz I heebyaffirm that I sou ficensedondaprovisions of Chapta9(commencing with
+100 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
6FZ�'; full r e end effect. / / ^ _ — ��
W f. f Cams Lic.# V w UP 00A x{' 1VTV
rn6a ale Convacror .201- API
Fy ARCHITECT'SDF. A A ION SQ.FT.IT.GOR AREA $/SQ.FT.
OZ�O Tun plans 6"HT us 1
Fye j Are. SIG EL CAL I I \ 348
a J Licensed l dexsioy I�1TJ
Ey. 6 / OWNER-BUIIAERDECLARATION SPE ALCM IT IS
O W U I hereby affirm Ila,1 am exempt from rhe Codus ctoes License Law for the
Say following reason,(Section 7031.5,Business and Professions Cade:Any city or county TEMP,
which requires a Permit an comwcl,alter,improve,demolish,or repair any swcture
}� prior ro in issnance,also requires the applicant for such ce.it,.file.signed statement POWER CES
W<0 that he is licensad ruuuam to the provision of to,Cnntrecam'a Licenselaw(Chepda
s Gy� 9(c.nan<ncin with Sectio.7000 of 3 ofthe Business and Professions Code WIMMI ELECTRIC
oµ, Sant )O ) VALUATION
_y or that he isexempt therefrom and the basis for the allegedmcmpti0n.Any violation of IITLES-SWITCHES-FIXTURES
k�} Section 7031.5 by any applicant tura peril subjects the applicant,.v rival penehy of
� � not more then five hundred dollars($500). NEW RESIDENTIAL ELECfR 5 Q.
W m ElI,asownerofthepropcny,ormyemployaswiihwagesmtheirsolecompensadon. Q STORIES TYPECONS'URUCION
y will do the w.rk,and the muriate asnm amendedor.ffered Im"Ic(Sec.7041,Business If
and Professions Calc:The Cnmmctor's License Law does not apply an an owner ofIllitttta
propeny who bui Ids m improves thereon,and who doea such work hi mal f or through his
own employees,providedthad such improvemma
ese not imendedorofferel forade.If, ALE ITS
however the bu ld ng onmprovememus.ldwthinnnc yeerofcompleunn theowncr- ® n n (i"� E R
budder will have the burden of rousing that he did not build or Improve for purpose of u—
❑)L as ownerofthe n clusvel tractm with lcensedanuuctors to QTVY. ' BdUMBINC PERMIT>�� ':� F.E". O [ E pr�
property.am ex yon g aw,,� Aa,:,, a it E' : 1$
construct the project(Sec.7044,Business and Profrssi.ns Cod,:)The Contractor's
License Lawdcesnot apply loan ownaofpmpery whobuilds orimproves0iereon,and PERMIT ISSUANCE
who contractsfonuch pmjccts with acomractons)licensed]pursuant me Conttacror's ALTER PA '4
Llc.s.Law. ( ) vr.,-R= s x .FEE-SUMMARY- -
❑"'I am exempt under Sec. ,B er P C for this reason BACK FLOW PROTECT.DEVICE O TS D s
Owner Data SANITARY Y - N_
DRAINS-!LOON,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑+thereby affirm lhatl heveoccrti0com ofconsenno self-amore,mit cenificete ofFIXTURES-PER TRAP RECEIPT#
Wmken'Compensmi.n lnsurancem.cenifted copy thcreof(Soc,3800,Leh CJ which PARK FEE Y N
covers all employee's under hia permit.
Policy# GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPr#
H NO SIGN FRES
Company GAS-EA.SYSTIiM-OVER 4(FA) PLANCI IECK IT: O
❑ Certified copy is hereby famished.
❑ Cenalied copy as filed wash the city inspection division GREASF:ONDUSTRI.WASTE INTERCEPTOR GRADING FIV
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPM
COMPENSATION INSURANCE SOILS
fTTis secdionnaJ not hecampleted if,hepermit is forone hund,W dollans($I W) SEWER-SANITARY-STORM EA.2MFf. EN0kGYkE
or]..)
I certify that in the perfmmatic,of the work for which this permit is issued,l shall WATER HEATER W/VENIDELELTR
ant employ any person in any manner an as to become subject to the Workers' PAID
C'O z yopPpe�'di.n L.wsof Celimmin. Date WATER SYSTENINREATING Detc
z 0 NOTICE TO APPLICANT:IL after making this Cmifiate of Exemption,you should NEW RESIDENTIAL Pi SQ,FT, c TOTAL:
Cn become subject m the Worker's Compensation provisions of the labor Code,you must
ficr ith comply will such provisions or This permit shall be deemed revoked. BUILDING
Q CONSTRUCITON LENDING AGENCY SEISMI FEE rli,
I hereby affirm That then is a construction lending agency for the Performance of .A EL PEE CJ
U C) the work for which this permit is issued(Sec.3097.Civ.CJ
lender's Name
u" F Lenders Address ¢�g? # �MBCIIANICAI PERMIT; - ` ' GING FEE
3`.I EC "
U 1 ready that I have read this application and sine Ned the above infmmorki is m$'T las S,b-)'f#Y I '* 'f'�
career, legree to comply with all city and county oNinanccs and state laws relating to PERMIT ISSUANCE MECHANICAL .F. �e
y building construction,and hereby authorize representatives ofdhie city loema up.mhe
U Z above-mentioned propaiy for inspection purposes. ALTER OR ADDTO MECH. �.. !PAID
RUCT 14TAX
(We)agree m save,indemnify and keep harmless the City of Cupertino ageinm
I ie 'lities,ju menu,msuandeapensawhichmaymanywayaccroe...imstmid Ciry AIR HANDLING UNIT(TO TO.000 CFM)
ce of rhe grunting of This permit. �
_V q AIR HANDLING UNIT(OVER 10,000 CFM)
m Co terror (, Dale EXHAUSTHOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10 100,000 BTU) to Receipt#
Will the applicant or future building occupant store or handle hazardous numdol
as defined by the CupeAno Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Coda Section 25532(x))
El Yea 1:1 No TILATION FAN(SINGLE RESIDI
BOILER-COMP(311P OR 100,000 BTU) ISSU CE DATE
Will the itcontamorfmurc buildied by the Bay Area Air Quality Management AID huzanit? air contaminants sea defined by,he Boy Area Air Quality Management BOILER-COMP(OVER 1181,000 BTU) M
DiaNc17
❑Y s ❑N. JUL 131993
N NEW RESIDENTIALMECII.—SQ.FT.1 have rend the hmadous materials requirements under Chapter understand
of the
if the building
Health&Safety Code,Sections ant,that
h 25533 and sponx.1 underhand thou CITY
if the of
does nmments l which
m st To e,Ari r 0 issuance responsibility m notify the L/r Vur T 11
cc.P.of the requirements which mull be mel prior m issuance.f o Certificate of
Occupancy.
Owner or amhmucd agent Dole ISSUED BY: