25949 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY J
PERMIT NO.
CITY OF CUPERTINO PLUMPING-MECHANICAL 25949
BUILDINGDIVISION APPLICATION/PERMIT BUILDINGPRO]ECTIDENTIFICATION
BUILDING ADDRESS:�']'{�// EE
O. APEl SURMfITAI.DATE
LOTH �w
7ARCHIn�/ENGINEUR:
: PI ONE: CONTRACT OR'S NAMG LIC#
9 OL#
• INEER: L NO: ADDRESS:
PHONE: '^ BUILDING PERMIT INFO
QT,Y. ELECTRIC PERMIT
w., ELECT PLUMB MF.CH
v'uPERMIT ISSUANCE
LICENSEDCONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL JO�DFSIONOttZmrthetlemlicenxed underprovisionaofChePter9(wmmrncingwithi ('W7`i100 Division J of the Business and Rofessiona Code.end my license ie in PANELS �d �
<VW lull
foue end eff« 3 IIP T0200 AMPS
F Z W Li«nu Clj Lic.N /G,///—GNB//////���������••
rn?y Date�Conuactm 201- Hal AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Z Ov`aiZ ARCHITECTS DEC N OYER IOOOAMPS
O Z to l understand roy Plans andl he used m public o 9.
SIGNS ELECTRICAL
QQ Licensed Professional
T�'KQ OWNER-BUILDER DECLARATION SPECIALCIRC'UMM]SC.
xdx OyU I hereby Mr.that 1 am exempt Even the Conaactor's Li«nu Lew for Ne
W mON followinguaa m.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MS
which requires a Permit to cemruct,alter.improve,demolish,m repair any nmcture
MoY� priorm its issuance,also requires the applicant forsuch permit to file a signedawtement POWER DEVICES
o that he is licensed pursuant m the provisions of the ComarminraLicense Law(Chapter
Oy, SWIMMING POOL ELE C VALUATION
aao 9(commenciagwith S«tion]000)of DiviaionJof Ne Business end Professions Code) _
m=m or that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of �—I�J�O
F3G
Section 7031.5 by anyoppletuat fora permit aubjecu theapplicam m rici i anvil yaf OUTLETS-SWITC -FTX'TURPS O[ /
O
not mare than five hundred dollars(9500). NEW RFSIDL ELECTS SQ.ET.
e' m C1I,mawnerofthepmpeny,ormy<mploy«swish wageamtheirsole«mpenseuon.
a3— will do the work,and the structure isnot intendedoro(feed for sale(Sm.7094,Business /STORIES TYPF.CONSTRUCTION
and professions Code:The Contractors License Lou,does not apply to an owner of
property who Wildsorimprovesthere.n,undwhodiassuch wml,himulforthrough his y _ OCf}C;ISOUP RES.UNITS
own
m
employees,provided thmsuchimprovementsare not intendedma(feted fnsde.If. II) V\Vy
however,the building or improvement is sold within one yeofcompletion,theowner-
builder .will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. � - � -PLUM13INGPERM � NLO NE APN
❑ Lus owner ofthe property,umexclusivdy romrncting with li<ensed<anoactaratn
.misses the project(Sec.7044,Business and Profusion Cale)The Contractor's
License Law doesnot apply manownerofpropery,who builds.,improvesreend
theon, PERMIT ISSUANCE
who contructs forsuch projects with econbuctor(e)licenxd pursuant o the Contractor's ALTER-0RAIN&VENT- ATER(JPATE
SUMMARY
License Law. -
❑ 1 um exempt under Sec. .B Jr P C for this reason BACK FLOW PROTECT.DEVICE T.I -
SANITARY YN
Owner Data DRAINS-FLOOR ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N_
❑ 1lerebyaffirm that l have a certificate ofcumenfto self-imuu,Ora certificate o! FIXTURES-PER TRAP RECEIPT#
Workers'Compenamion lnsumnce ora cerifiedcnpy theuvf(Sec.3800,Lab C.)which PARK FEE Y_N
rsii eropl ye' y nth' iL O rl GAS-EA.SYSTEM-1 INC.40UTLET RE:CEII'TN
Policy# U /T BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is euhy fomished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE CEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thi medromed not be complete 'f Ne permit is for one hundred do11as(5100) SEWER-SANITARY-S RMEA.IWFT. ENERGY FEE
artless.)
I certify than y TO ..On fthe odforwhichthispei sit I.Imam.I that WATER HEATER W NT/ELECRR
not employ any n any m u to become sot 1' n' PAID
Compo iv if ' - WATER SYSTEM EATING Date Receipt
O z Applicant
Z NOTICE TO APPLI :14 (mins i hieCmifiva of Exemption,you should NEW RFSID IAL PLMB. SQ.FT. TA
(ZI becamesubjmt m In Wmkera o nu prvvisionsofdolabor Code,you must
forthwith comply with such provisions m this permit shd)be deerned revoked. BUILDING FEE
OW., Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby fifrm that them I,.construction leading agency for the pM.ce of TOTAL: ELECTRIC FEE
V O the work for which this permit is issued(Sec.309],Civ.C.)
Lendees Name - PLUMBING FEE
k' F Lendds Address QTY. MECHANICAL PERMIT FEE
O V 1 certify that I have mad this application and sate Out the above information is MECHANICAL FEE
W corset.I agmetormadywith all cityandcountyardinan«sand sum laws mlaGngm PERMIT ISSUANCE
E" � building construction,andhembyamhmim mpaemntieli of Niacitymrnmrupon Ne - CONSTRUCTIONTAX
1, z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmlos the City of Cupertino against
Iiabiliries,judgmena,costa and expenses which may in any way accrue agalmi mid City AIR HANDLING UNIT(TO 10,000 CEM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Commctor Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(By IOg0011 BTU) Data Receipt
Will the applicant or future building occupant sort or handle hazardous mammal HLATING UNIT(OVER 100,0008
ea defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section]S5J2(a)1 VENTILATION PAN(SINGL ESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant or foods building Occupant use equipment or devices which emit BOILER-COMP(JHPO 00,1100 BTU)
• hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OV 100,000 BTU)
District]
❑Yea ❑No NEW RESIDENTI MECH. SQ.FT.
I have read the hazandous mumri s r uimments under Chapter 6.95 of the p I
California HealthffictyCodle.hSOctiols 255 5,25533 und255J4, lundersand that M
if the builJingr anM
Owner or au a imgent o TOTAL: ISSUED BYe
OFFICE ur l4urtHIINU