25663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RICAL APPLICATION/PERMIT PLUMBING-MECHANICAL. PERMIT NO.
BUILDING DIVISION BUILDING PROIECI'IDEM'IFICATION 256643
RUI ING ADDRESS: �•r�aq,y�/(v.�. SANITARY NO. APPIJCATIONSf1BMfITALDATE
21 J19 �{ �av UNIT# LOT# 10-:14011
ERSNAME: � , EO�N�P���—aCONTR PR'S t`!pM`�n LIC NO:
N/C CONTROLM
• s
CHITECT GINEIIt LIC NO: ADDRESS: Y ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY.,=.o ELEG'fRIC,jPERMIT, FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ❑ lyt ❑
an doulSBD CONTRACTOR'SDECLARATION pppLIANCES-RESIDENTIAL � IO Wp'TIOpL iaa
CZ IherebY affirmCENSE licensed islomaf RANI 9(commencing with
00 Smalon 70)O of Division 3 offs,Business and Professions Code,and my license is in PANELS
yUEfail fare,and emact.
FZLicy)
ense Class Lit. UPTO200AMPS \ �W
ooQ y Data Contractor 201-1000 AMPS
SFO yZ ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR ARG S/SQ.PT.
OZ-0 I understand my plans shall be used as public records.
co J SIGNS ELECTRICAL
Q� ,� Licensed Professional
is; OWNER-BUILDER DECLARATION SPECIAL CIRCUIT`MISC.
ipy#S�.O yF 1 hereby affirm Na[I,fact exempt from the Contractors License Law for the
W 3 Q ran following reason.(Section 7031.5,Business and Professions Code:Any city orcomry, TEMP.METER OR POLE INST.
Ipp-'�rn J which requires a permit to construct,aper,improve,demolish,or repair any structum
I ¢� prior to its issuance,also import the applicant(orsuch penniuofile a signed sutement POWER DEVICES �-
cc�Na O
[bat he is licensed pursuant to the provisions of the Conommes License Law(Chain
Ly 0 Division 3 of the Business and Professions Code) SWIMMIN
9(emnarmcinth Section7").1` G POOL ELECTRIC h
yds,, or that he isxmlt therefrom and the busis for the alleged tion.Any violation of I -• I: ! UA ON
Waco eeP e p
'Y Steri ]U31.5 by any applicant for a permit subjects the applicant m e civil pemiry OUTLETS-SWITCHES-FIXTURES of
n are Nan five hundred dollars MOB. NEW RESIDENTIAL ELECHT S .
pw I,uownerofthepropeny,ormyemployeeswiNwaguas Neirsolecompmutim, TYPE CONS1BUCfION
y3 wflldothework,and the structureisnot imendedorofferedforsele(Sm.70,14.f3mineel D •-i E
and professions Cade:The Contractors License law does not apply to an owner of
pmpeny whobuildsorimproves thereon,and whadoes such work himcifortluaughhis OCC.GROUP RFS.UNITS
employma,provided Nre
at such improvements unoed
tintendedoroffmfasafe.If,
however,the buildingor improvement is sold within one year ofcompletion,theownm ,TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). "
[II,asownerofthepropeny,ameulusivelywn cfingwiN]imn cons wnw QTY. PLUMBING PERMIT TEE ____F GOD APN
consumer the project(Sec.7144,Business and Professions Code)The Contractors PERMIT ISSUANCE
License Low does not apply to m nee ner of ponjunry who bui lds m improves Nerwn.and
who commets for such projects wi tha con tuc togs)licensed pursuant f o the Contractors
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C fm this moonBACK FLOW PROTECT.DEVICE SANITARY OU I S N
Owner Data pRAINS-FLOORROOF.AREA,COND. RECEIPTN
,
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX YN
❑ Ihcreby affirm Nulheveettrtificew of comer mself-inaum,maarti0caa of RECEIPfp
Workcr%Com notion lnsumnce oncrnifiedc FlXl'URES-PER TRAP
pe spy thereof(Sa.3800,Lab CJwhich PARK FEE YN
C.ceratill employees under this permit. GAB-EA.SYSTEM-1 INCA OUTLETS R
Policy If DIVISION BUILDING DIVISION LEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF.
❑ Certified copy is hereby famished.
❑ CrniBed copy is filed with Ne city inspection Nvision. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lithe Permit isforone hundred dollars($100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or lees.)
I unify that in the performance of she work for which this permit is issued,l shall WATER HEATER W/VBNT/ELECTR
not employ any person in any counter is,as to become subject in Ne Workers' PAID
,z Compensation Lawsaf Califomie. Date WATER SYSTEM/BBATINO Oar Receipt#
Applicant
C NOTICE TO APPLICANT:IL uRtt making this Ceoficate,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
{--r (04] became subject to the Workers Compensation Provisions of the Labor Cade,you must
N+ 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING ME
W QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
7 1 herby affirm that there is e construction lending agency for the performance of
the work fm which Nmit is peris issueded(S(Sec,,3097.Civ.C.) T ELECTRIC FEE
Lender's Naar
O ." .` PLUMBING FEE ezi
Iander9 Address Q'1•Y.' MHCHANICAL PERMIT PHP.
1 aNfy Nat I have rand this application and aur that the above information is '�r;;r:, ..
Q. correct l agree to comply with all city and county ordirances sad slate laws relating to PERMIT ISSUANCE- MECHANICAL FF.E
Nbuilding construction,and hereby suthoArompresenlatives of Nis city to micrupon the CONSTRUCTIONTAX
U Z above.nottionam property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupenim against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO IQUW CFM)
in consequence of Ne grwfine of this permit.
rj_ - 16 ,�I AIR HANDLING UNIT(OVER 10,"CFM)
JaAAe— Dam
nature of ApplicanVCnnwcwr EXHAUST HOOD(WIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I0Q000 BTU) Date Receipt#
Will the b,,he Captoant rfuwrebuildingmcupaut pewreo.handle madthhm ireaus althan material HEATING UNIT(OVER 100,000 BTU) TOTAL:
u JeOned by the CUPenina Municipal Code,Chapter 9.12,end the Health and Safety
Code.Section 25532(a)T
E)Yes ❑No VENTILATION FAN(SINGLE RE$ID)
Will thea licamorfuum buildin aces BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
pp g hems,Area an Quality
Management A D
heaardous air contaminants as defined by the Bay Area Air Qualify Mragement BOILER-COMP(OVER I(ML000 B'fU) P4
District?
❑Yes ❑No
NEW RESIDENTIAL MECH. SQ.FE /IAT p y
I have read the harardous materials requirements under Chapter 6.95 of the , V{/ cif 1
if
ia Hlth does at cur Code,
ntlyhaSections 25,that it is yanspond 34.IutMersund that CITY Vr Guertl
if the building doesnae entswhaveast he that it is my msance off enotifythe
occupant of the requirements which must be mm prior to issuantt of a Certificate of 7
Occupmcy.
Owner or tahmiaed.,an, Date TOTAL: ISSUED BY!=(/'" s'
OF I