25985 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOMTCATPLUMB N PERMIT NO.
MECHANICAL
25985
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDRN1IFICA1IO
BUILDING ADDRESS: I
�//�,s SANITARY NO. APPCATIONSUB1MI1TTALDATE
1o35I -(2oA-0UNITN LOT �I�tT
OWNERS ME: �V PHONE: IlpCJ1'ORC N AND: NC ` CONTROL11 1
NRCHITEC/ENGINEER: V LIC NO: A CS SB�R /'� /� ❑
CONTACT: PHONE: " " - "; " .0:3.z _ BUILDING PERMIT INFO
QTY- `' ,r°J"6LEOTRIC;PERMIT - FEE
'vA ?,rs"!'7, .' sess— BLDGPLUMB 'CH
/PERMIT ISSUANCE / itF.CT 1:1LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL
I h303 affirm amliceasedunder (Chet 9 with TOB DESCRIPTION
caz hereby proviamnra per (eommmeing
a�100 Section 9 )soG-ffs..Division
�3 o—f the Business and Professions Code,end mylicanre is in PANELSstr
,znj fullensa CE e Lic.p X��0R` IIP T0200 Ah/P5
not U Dae Conuacmr 201-IOOOAMPS S .E%FLppppppggg...AppRF� S/SQ.FT.
Cz-Q ARCHITECTS DECLARATION OVER IODO AMPS ps p R 11 �'1
I undersrvnd my plain shall be used as public recoNa. B6Vg /r.11� 111" I�'/ L
W SIGNS ELEC IUCAL
Q Y Licensed Professional
`5 aU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.1V- 1 hereby affimn that 1 am exempt from the Commandoes License Lou for the
3 LLm following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
C which requires u permit to construct,alter,improve,demolish or repair any rade ATE
ire Prior to its issuance,also imports;do eppliunt forsuch permiUofilea signed moment POWER DEVICES ..J
p pp� that he is licensed pursuant to the Provision.of the Co rracloes License Lew(Chapter SWIMMING POOL ELECTRIC VALUATION
'0.a MLL 9or t that
he is ixemithgeniromandme Division 3oftheBusiness and PnAny vilaCode) _
,Z- Secti heises byran,pt therefrom and me Farm!,onheem don ,deanexemption.Amyl violationof
UTLETS-SWITCHES-RXTURES ^/a—TSe�s/<.`J`
F Z.< a.,aonedran live
dyed do[[ ($50dnit subjects the applic�nttoecivil penalty
$sT, not more than five hundred dollars(5300).� NEW RESIDENTIAL ELECTR —SQ.FT.Co ❑ hmownerofthe property,ormyemploymswith wagesertheirmlecompema4on, Q STORIES TYPE CONS'IRUCHO
ya: wil l do the work,and the structure is not intended or offered for sale(Sm.J044,Business
end Professions Code:The Contractor's License Low does not apply to an owner of
property who buildsorimprovesthereon,and whudoes such workhimrelforthrough hi¢ OCC.GRO P RES.UNITS
employew,providedthm such improven¢msere notimm�ded oro(fercdforsele.If,
however,the buildiagor improvement is sold within one yeaofcompledon,Ne owner. T
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lmownerof the Propercy,vmexdusivelycmmading wiNiicensed conmaztorsm QTY,_ PLUMBINGPERMIT FEE R.00D ZONE APN
consumer the project(Sec.7014,Business and Professions Cade:)The Contractor's
License law does not apply 0 an ownerofpropeny who builds or improver thermn,and PERMIT ISSUANCE
whocanmams forsuchpodecs wide acoatmes r(D licensed pursuant to the Commoner
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY YN
Owner Date DRAINS-FLOORROOFAREACOND. RECEIPTN
, . , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihemby affvm thatlhave acenificme of<onsmno sel0insure.oracenificateof FlXTIJItfS-PER TRAP RECEI tt
Wmken'Compen.etion lnsmance oracenifiW copy Hereof(gen.3800,Lab CJ which PARK FEE Y N
mvars all employee's under thist. Ink
PC1nt' GAS INC.IN40lITLEfS
Policy N MFWW,6jVISWN .S
Company GAS-EA,SYSTEM-OVER 4(EA) MANCHE Q
❑ Candied copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASENNDUSTRL WASTE INTERCEPTOR GRAD G
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPS S E
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is(mane hundred dollars(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in Ne performance of the work for which this permit is bared.l shall WATER HEATER W/VENT/ELMTR
not employ any person in any nunner m as to become subject to rhe Workers' PAID
Compensation Laws of Celifomm Date WATER SYSTEh1/IREATING Date meiptg
0 z Applicant
z 0 NOTICETO APPLICANT.IL after making Nis Cemficmoof Exemption,you should NEW RESIDENTIAL FILMS. SQ.FT. TOTAL:
r: '4 become subject to the Worker's Compensation provisions of Ne Labor Cu le,you must —rs
foMwiN minPtY with such provisions or this pnitahall N demand revoked. BUILDINGFEE
SEISMIC FEE
(,]
CONSTRUCTION construction
AGENCY
Ihemby which
Net there is a and(Sm..3 lending agency for Ne pertonnanw of
U O pcnni 'TOTAL: ELECTRIC FP.E
Leader's Name
U" F^ Lendeea Add.. QTY. MECHANICAL PERMIT . FEF. PLUMBING ICF.
LVI certify Nnt 1 have read Nis eppiiwtion end stag Net the above information is "" MECHANICAL FEE
cosecs lagme mcomply withall citystd countymdineocw andstem laws rela0ng to PERMITISSUANCE
�^ y buildingconmvction,end hereby authorise rcprcsmmtiver of Nis city meaner upon the CONSTRUC IONTAX
U z above.mentioned property for impaction purposes. ALTER OR ADD TO MECH. ��
(We)agree to save,Inde and an rep hmmleas the City of Cupertino against
uI he u . and 'chin nywayaccreeegaiad City AIR HANDLING UNIT ITO 10,000 CFM)
in inn qucneof goonof is it. ,a AIR HANDLING UNIT(OVER 10,000 CFM)
Aigoolan,M ApplicamVbn trot ¢ EXHAUST HOOD(W(DULT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1 W,000 BTU) Date Receipt p
Will the applicant or foto building occupant store or handlehaaradousmmmial HEATING UNIT(OVER IW,(I(10 BTU) TO
as defined by the Cupertino opal Cada Chaprcr 9.12,and the Health and Safety
Code,Smtiun 25532(e)? �/�d�jn VENTILATION FAN(SINGLE KESID)
❑Yea IIENot ISSUANC ATE
WilHheapplicanmrfmuuildingnccupantuwcquipmentordeviceswhichemt BOILP.R-COMP(3HPOR 100,OWBTU)
vm. air,comeminancs defined by the Bay Area Air Quality Management BOILER-COW(OVER 100.001)BTU)
District?
❑Yes No NEW RESIDENTIAL MECH.—SQ,FT. {p //��
read the hueardous materials requirements under Chapter 6.95 of the P A Y
1
Coliforms Hea actions 25303,253is and 25334. I undersand thin
if the builJin on c ly ee¢nand, my respunsibiliry son tify the
ama ut a tr to issuance f/ e t of
V
Ownerorrodama:dagem ISSUEDGY�
OFFICE