25913 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIE61NIT-EI.FCTRTCAL PERMH NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDFINI'[FICA'I'ION 25913
BUILDING ADDRESS: c SANITARY NO. APPLICATIONSUBM=DTAALDA'IE
l
/ Q /(7DR �al-G—N)1 J ON, / (��UNITN LOTp
OW FIRS PHONE: CONTRACTOR'S NAME LIss,,NO: NIC CONBOLp
ev G .2E.¢7CT O(J6H C"vc/S
RCIII JECT/ENGINEER: LIC NO: ADDRHSS: C "L J�� �� C E ❑
CONTACT: PHONE: iL
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
2051---3
j (/ 2 BLDG ELECT PLUMB MF.CH
L Z T ---3 176 PERMIT ISSUANCE .QCI Fl� `LP.j-`Ar
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB D RIPDON
pxZ I hereby affirm that l am licens underprovisiomasfChapm9t,..m ncingwith y.
=00 fallf ve andefDivision 3.f the Business and Professions Code,and my license is in PANELS �O �� �\' II 1s�
UU full force and cflccL 7 11
<,, License Class Lic.k UP TO 200 AMP$
.<a- Date Contracm, 201-1000 AMPS
>O,Z ARCHI'I EC'rS DECLARATION OVER 1000 AMPS SQ.Fr.FLOORAREA S/SQ,FT.
O Z_O 1 understand my plans shall be used as public records. _
F..y F; SIGNS ELECTRICAL r '— ^p q Iyl
<wnia Liccmcd l'rolbssionel OWNER-BUILDER DECLARATION SPECIAL CIRCUEDfdj,C. h I /P', _ E I'.�J' I)
KKO W F 1 herehy affirm thin 1 am exempt from the Contractor's License law for the _
WwOrr hallowing marnn.(Section 9031.5,Business and Professions Cade:Any city n(county TEMP.METER OR POLE INST. II
I_'_ which re t t.cormum alter,imitative, _ l t
tn� quiresnpanni for such
permit, an POWER DEVICES a
E"ZY0 that he itsissuance.
pu uant to therea provisions
fofic Co permit's Lifilcase Law(Chapter
sommrnt
�C�p 9 ocomislicarsalp Sectiom0,0provisiision the Contractor's License LniansCds) DALE ,
aa�K 9(commencing with Section 7000)of DivixionJohhe Business and Profcuimns Code) SWIMMING POOL ELECTRIC VALVATION
u' Cr that he is exempt therefrom and the basis for the alleged exemption.Anydd
tail_'tn Pt li1pradsn of OUTLETS-SWITCHES-FIXTUB (/ v
�z 4 notSectionm 03 1 than by any hundred
dans fsr$500).t,wbjecu the applicant m u civil penalty of
BIT—
not m.rethanfavehun dollars($500). NEW RFSIDENTIALELECIR SQ.FT. STORIES TYPECONS'IRUCTION
YKY]]Fo ❑ othe wnr,a thcp,.pc(ry,mmycmpindedorthwed forsthei(sale ec.compensation,
y3°Jm will dothcwons aide: Ile Contractor's
License ufwdoes not
to
wrier ss
of
land Professions Code: Ile Cm loc'o's License law uses or apply to an owner.f
property w yeas,Novi improvesh improvements
and w is arcs such work oroff fedtlwuge.his
own employees,provided that suchimprnvrments arc not imcnded.rolfcred forsale.If. OCC GROUP RES.UNITS
however,the building.,improvement is sold within one ye.rofri m sletiom,the uwrc( 15
-
builder will have the burden of that he did not build or improve TOTAL: 1,
pr.vin6 prove for purpose.(
sale.).
❑ 1,asoverrofthe property,inn exclusivelyc.nraoing with licensed contmemrs to QTY. PLUMBING PERMIT FEE 11000 ZONE APN
construct the project(Sec.70f4,Business and Professions Code:)The Comfacmrs
License Lawdrcsnmapplymanmwnerofpropeny who builds.,imprsvesthercon,and PERMIT ISSUANCE .(7
whm C0amaC1s for.suchpmjectswithaconracmr(s)licensed pursuant to the Contractors ALTER License Law. FEE SUMMARY
❑ 1 um exempt under$c. ❑&P C far this rca+on BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE:FEES N
so— Owner Dme RFCEIP(.
DRAINS-FLOOR,ROOP,AREA.COND.
�$ WORKMAN COMPENSATION DECLARATION SCHOOI,TAX Y N
[hrorkera oraterrmic, Ins veoceniceniricate coUt mof(imua,nracertifwlwf / RF�ISII'1'N
Wse..2 Cmployee,onlmumisprri ni0ed copy share.((gee.Jg00,Lab C.)whi<h FI%TURES-PER TRAP —�(,� NARK FEE Y N
covin all cmpinyKsundo this pcnnio. GAS-ITA.SYSTEBUILDING DIVISION
INC.4 OUTLETS REVISI p
Policy M ON FITITS
C�oyt Cert GAS-EA.SYSTEM-OVER 4(EA) PLANCHFCK FEE
® Cenifird copy is herebypermitted.the M.
(7 Ccnifed copy is fled with the city inspection division. GNEASI%INDUSTRL WAS'1'E INTITRCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
('Phis section need not be completed ifthe permit is formic hundred dollars(S100) SEWER-SANITARY-STORM EA.2008. ENERGY FEE
or less.)
I minify that in the performanceofthe work for which this permit is issued,I shall WATER I IHATER WNENOELECTR
not employ any person in any manner so as t0 became subject to the Workers' PAID
Z Compensation Lawsof CalifOmia. Date WATER SYSTEMITREATING Dam Receipt
Applicant
O C) NOTICE TO APPLICAN'r:If.after making this Cenificamof Exemption,you.should NEW RFS]DENI'JAL PLMB. SQ,IT. TOTAL:
become subject to the Wmker's Compensation provisions of the Labor Codc,you mann
a foMwith comply will such provisions or this permit shall be domed revoked. BUILDING FTTE s l70
G CONSTRUCTION LENDING AGENCY SEISMIC FEE ' 00
UI hereby affirm that there is a construction lending agency for the performance of vv��O the work for which this permit is i.ssued(Sce.3090,Civ.C.) TOTAL: .(,V ELECI RIC FEE tom/- 7
lenders Name PLUMBING FEE
LL1�
OF l<nlres Address QTY. MECHANICAL PERMIT FEE 3 n Q)
L.) 1 certify that 1 have mad this application and soon that the above information is I
>" Fl] smooth. lu ,a meso l th all cit ucuunt Jimmcea andstale lows rclnoin m PERMIT ISSUANCE MECHANICAL FETE �4
1 B pYwi yam yor 8 ,OD
F' aft d n, crebyauthoriu mpmunuoivcs of this ciry to corer upon the
C1z aM,veWe)e)agree propcny forint .xs. N.TERORADOTOMF.CII. CONST'kUCTION TAX
(We)agree m save,km=llke less the City of Cupertino against n fIIiabilitiu.judgmcnD,c hichrtay yweyeccrveagainnsaidCity AIR HANDLING UNIT(f010,000 CFM) 1-J,f._ ~ �/4'irom,r' a,uccofthrn.
2I AIR HANDLING UNIT(OVER 10,1100 CFM)
Signawrc of Appli VCommmm Dam ITXHAUST 1100D(W/DUCI'1 a PAID
HAZARDOUS MATE RI LOSURE HEATING UNIT ITO 100,000 BTU) Date keccipop
WTIIth pplicano or future building occupant store or handle hazardous material IIEATINO UNIT(OVER IW.000 B"CU) 'TOTAL: �ee.a
as Jclbmd the Cupotlno Municipal GWe Chapter 9.12,and the Health and Svfny
Code,Section 25532(a)p
El Yes 13 No VENTILATION FAN(S WGLE RESID)
ISSUANCE DATE
Will thea liewoor(murcbuilJin tux BOILER-COMP(dTTP OR IIXI,fgO RTU)
pp gby the equiPtvanto(ality Management
A n
District?
air cnmaminanu as defined by the Bay Am Air Quality Managemem BOILER-COMP(OVER I(6U1o0 BTU) Q
Distrial
❑YLbuilding
s ❑No NEW RESIDENTIAL MECH. SQ.FT.
mad the hazardous annerlaln nectm corms under Chapter 6.95 of the FEB 14 1994
ealth&Safety Code.Sections 25505,25533 and 25534. 1 understand that
g docs notcurrently have a mmmr,that it is my responsibility to notify the
the requirements which must he met prior to issuance of a Cenlficate of III I 1 Vf vvr u t t rslho(izcd a6cm Dam TOTAL: 1 ISSUEDBY: xsl � -✓L'Ll.� Vl
OFFICE l 3