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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
j BUILDING PRODUCT IDUNTDlCAT10N;j{>::;7>§:x""
PERMIT NO.
25332
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
L 1_�rs
G
11/{ y UNIT# LOT
OWNERS NAME: PHONE:
CONTRACTOR'S NAM LIC NO:
NIC
CONTROL#
+\RCHI 'LT GINEER: LIC NO:
.
ADDRESS:
O ACT'
HONE:,
.. ( fa. *�>.' Iw nn r :�.: rats �3: �„': -, A..'rc:..A:
QTY.q.BLECI'RIC PHRMITV(ai ^`r3'?AP,-,EMI;.
- `. BUILDING PERMIT INFO'
BLDGCf PLU MECH
PERMITISSUANCE
N
{�
LICENSEDCONTRACTOR'SDECLARATION
1 rc affirm Netl am licenseemelarprovisionsof LTapter9(commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Semian fOivisicn 3 of N<Business and Professions Code. and my license is in
full farm and effect.
PANELS
LiccnseClass Lic.k
UP TO 20) AMPS
R09I
201 - IOW AMPS
Date Convector
ARCHITECTS DECLARATION
1 undersand my plans shall heated n ec
public rords.
OVER IOW AMPS
D SQ. FT. FLOOR AREA ` LSQ. FT.
I / !.i ��
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUm.DER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that 1 am exempt from the Convectors Law for she
1^ —
L aa
TEMP.MEfER OR POLE P1gT.
Code: Any city or county
e: Any
following inxamesa
l
armat to construt,aver, ianrove. dssions
pollrt rtGY1R3aperlmt cmasthealter,Improve•h pair myx6god BQannom
i Ne applicantfine pemtiUoLicesignedsmemmt
permat fie
prior to iuissnsedlprnarmn.
POWER DEVICES
the Co
Nathem usingw pmsumno0( oil Diomof the Contractors License Lew s, Coder
Professions Code)
9(commeis ixemitt Section70(1aW)of Division Sof Need ascription.
Ne Perisfartheaseged nempsion. Myvioledon of
Semon 1031.5
Sectionat 70 1.5 by my applicant
any dmt far a Permit subjects the applieanno a rivil penalty of
SWIMMING POOL ELECTRIC
yAI,UpTIOy
V S
OUTLETS-SWITCHES-FI%TURES
fivedyed
raw ml. Nenfivehundreddollar(SSW).
❑ I,ssownerofNepropcny,armyemployttawiN wegnntheiraolecompensedon,
NEWRESIDENTIALELECIR_SQ.FT.
STORIES TYPE CONSTRUCTION
will do the wmk• and the swctare is not inumdead or offend for sale (Sec.1044, Business
and Pmhousena Code: The Contractor's License law does am apply to m owner of
property who builds m improves Merton, end who don such work himself or through his
wnemployees,provided that such impmvemenuarenmimendedoraffe forWe. If.
nr p g
! A - _ � UNITS
LE D
however, the budding or improvement s sold within oneyearofmaeopletion, thatiouniAL
builder will have the burden of Proving that he did not build or Improve for purpose of
sale.)
^yin ,
APN
Q7y, t�' ,�p�`'pP..L.. ;:2 _ ,,„�
UMBING PERMIT" sy'' _ Vie. �E iff.
❑ I.nownerofNepmp M,emexcluruelycomrctingwtNlmensedcwmct u
construct the pmjact (See. 104IL Business and Profession Cade) The Contra,
Liam Lawdecanot.pplyto an ownerofpropery who buiidsorimprovestheremn,mdPERMIT
;,}y x+wmsr -in•: m^Ae„ fi.� _ n..v
'dry
�ON
TE O
t
ISSUANCE
who contracts forsuch projects;witha,inatmer(s) licensed Pusuantmthe Convectors
License law.
ALTER- DRAIN & VENT - WATER (EA)
.;,.a;N_54'"r.iY+FEE $UMMARY�t'•,r .. Vic,. -:.:.
❑ 1 am exempt under Sec. , B & P C for this rceam
BACK FLOW PROTECT. DEVICE
SANITARY Y _N
RECEIPT #
Owner Dam
DRAINS - FLOOR, ROOF, AREA, COND,
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX N
YRY
dqbW❑ affirm haves neofconsmtmself,memrlficm ohf
mkem'Com1 oracertifedcopyNertof(Sm.38W,LbCJwhic
ECEIPT#
FL\TURfS PFR •TRAP
PARK FEE N _
cover of employans coder this permit
Policy N
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BULLDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREASEiINDUSTRL WASTE INTERCEPTOR
GRADING FEE -'a,
❑ Cer iced copy is filed with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
_
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Tldssection need not be completed ifthepetrut is for onehundred dollar( SIM)
or less.)
WATER HEATER W/VENDELECfB
I tartly that in the performance of the work for which this permit is iraued,I shall
not employ any person in any mourater m as no become subject to the Workers'
PAID
Compensation Lawsof California. Dam
Application
WATEBSYSTEM/fREATTNG
Data Receipt#
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
NEW RESIDENTIAL PLACE. SQ. PT.
TOTAL:
become subject to the Worker a Compensation pmvisioms of Ne Labor Code, you most
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE �^
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hemby affirm that there is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
L
-,l.•,aa -nt-�
ELECTRIC FEE sis
1
Lender, Name
Lender's Address
W"$ s ixuvp ? va' d
QTY'k' `� MECHANICAL PERMIT .� S�H4
raw
PLUMBING FEE �a
1 cantly that 1 have rtad this application and state that the above informal oat's
corset Iagree to comply with ell ciry and county ordinances end rmelaws rcletingm
" l b
PERMIT ISSUANCE
MECHANICAL FEE
building construction, end hereby euthoriu representatives of Nix city to enters pm Ne
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save. indemnify and kap harmless the City of Column. against
]iabilii s,judgmenu• cons. and expenses which may in my way ccByeg ins, mid C'
th co c e of the Prmring of this permit^I//w�'
AIR HANDLING MIT (TO 10,000 CFM)
apiicanVContrector
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (W/OUCO
PAID
ign u f Data
HEATING UNIT(TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receip,0
HEATING UNIT (OVER 100.000 BTU)
TOTAL:
ill the aPPicmt or future building occupant store or handle hazmdous materiel
as defined by the Cupertino Municipal Code, Chapter 9. 12, amt the Health and Safety
VENTILATION PAN (SINGLE RESID)
Code. Section 25532(.)?
13 Yea CI Na
ISSUANCE DATE
Amen
Will Nee licanmrfmure buildin ms< vi mrdeviceswhich emit
pP 6
BOILER - COMP (3HP OR 1W.gq BTU)
BOILER - COMPIOVER 100,000 BTU)
by the A
District? dr conteminm. n defined by the Bey Arca Air Quality Mmagemem
District?
❑ Yes ❑ No
l
NEW RESIDENTIAL MECH. SQ. FT.
I have odea the Instrument tyCothmaterials 5505.25533 under Chapin erm d the
1underoll that
Californiaing dos aferyentlyhvea m SS05at it
if the building does rat currently have a tum,, Net o is my responsibility m omify Ne
y responsnd 25534+ibility
occupant of the rcquiremena which mus, ed met prior to issuance of a Certificate of
Occupancy.
r� 1
I& �6\\\v
C a
1/(Iy
ISSUED BY: '
Owner or authorized agent Date
OFFICE