25983 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OE CUPFRTINO L7117f.NT.-""I'll PERMIT NO.
APPLICATION/ GPERMIT PLUMBING MECHANICAL 25983
BUILDING DIVISION BUII.DINPROJF.(TI'IDENTIFICATION
BUILDING ADDRESS: Is( e /'/i n SANITARY NO, APPLICYHONSUBMITTALDATE
/0-7-7/ V sa I - - kANfTi LOT# 1 _ 4/_q'/— / _q /
OWI,Wj NA I PHONE: C�NTRACTQR'S NAME � /.> LIC NO:
LA �14b - 36 �� a/C L�. / If we CONTROL»
. ARCHITF:CI'AiNGINCER: .LIC NO: 36Z 5;-1111t,
R F-1
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ II�1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
qWz I hereby affirm that l um license underprovislonsof Chepter9(commencing with TOB DESCRIPTION
wW'00 swhan TBao nruroiamn3onne Business ma nares.>ima�c/�e,sena tar license is in PANELS RP,Q(, ii W — SeF./( t�'
Fj�QtF. fulll'oreeandeffca f50 Up T0200 AMPS u
License Clens _�� Lie.Or y�
y<y Do. Contractor 201-HIMAMPS w s rs�s G U
ZpyZ ARCHITECTED RA ON OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
0z plans"O I understand my plashall Is,used as ublic records.
SIGNS ELECTRICAL
Q Y E j Licensed m
Professnal
K
=Q OWNER-BUILDER DECLARATION SPECIALCIRCUMIMISC.
XO y F I hereby affirm thin 1 am exempt from the Cmaracmr's Lies.1<w for the
w 3 a m following mason.(Section 70315.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. B /� I\ II
which rcyuires apnma
il to construct, demolish,or pair any structure J OM1\VY
fY� pannoi¢issuunce,nlwrcquirts the applicant forsuch pertniuo Gleasigned stnxmmt POWER DEVICES
is: <z that he is licensed pursuant m the provisions of the Contractor s License Law(Chapter SWIMMING POOL ELECTRIC -CPA
`L eLL 9(commencing with Section 7")ofDivision 3ofthe Business and Professions Cade) L
w-m or that lie is exempt herefrom and the basis for alleged exemption.Any violation of
i".'ZQ Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
ESQ maroon,than five hundred dollars($500). DAT
pew ❑ I,ueowncrolihe n NEW RESIDENTIALELECTR _SQ.FT.
grope y,ormyemployeeswithwagcsnsrheirsolecnmpensauon, STOH iSI TYPLC XDOULTION
will Jct the wmk,and the surmount is not intended oroffcred forsale(Sec.7(44,Business
and Pmfe"inns Coale:The Contractors License Law does not apply to m owner of
property who builds m improves thereon,and sources such work himselfm through his
cmployess,provided that suchimprovements menot intended oroffcred fmsale.l[ OCC.GROUP RE$.UNI'I'S
however,the buildingor improvement is sold within oneyearofcomphetion,the owner- TOTAL:
builder will have the burden of paving that he did not build m improve for purpose of
sale.).
❑ l.mownerofthepropeny.amexclusivelycomreaingwim]iena wnwcimto QTY. PLUMBING PERMIT FEE TLOODZONE —AN
coastal the project(Sec.70 1,Business and Professions Cale:)The Crimean's
License Lawdeasaot apply man ownerofprope0y who builds or improves Naaon,had PERMIT ISSUANCE
whocontracts forsuch projects with acoomicum s)licensed pursuant to the Containers
Liccnx Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C far this mason BACK FLOW PROTECT.DEVICE: OUTSIDE FEES
OwnerSANITARY YN
Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT#
• c
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby
ar,1zeaffirm ihinlhaveecenificate ofwnsem nr self-inaurc,ora cenilicate of FIXTURES-PER TRAP RECEIPT#
Warkeri Cnmpenmtionlneurunce oracenifiedcopy thereoflSw.3800,Lab C.)which PARK Flip YN__
cs# employyee's unnder this permit,>
1'olicyp—/_b/0 L t✓c / GAS-EA.SYSTEM-I INC.4OUTLETS RF.CBIPT#
Company n.^. BUILDING DIVISION FEES
Cl Certified copy is hereby furnished. GAS-EA.SYSTEM-OVER 4BEA) PLANCHECK FEE
W Ceni Oed copy is Bled with Ne city inspection division.
GRFASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' F,
COMPENSATION INSURANCU GREASE TRAP SOILS FE
(This section need not be completed ifthe pcmtit u torose hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY HE
less.)
Icertify that in the peAnammeeofthe work for which this pvmi,is issued,I shall WATER HEATER W/VENT/ELECIR
not employ any peen in any mame,so as m become subject m the Workers PAID
Z Compensationlawsof Califomia. Dae WATER SYSTEM/IRGTING
Dote Receipt#
z O Applicata
z NOTICE TO APP Le Work rsIf,after Compensation
this Genion of the
Labor Exemption. should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F > bac ns the reply the Workers Compensation prevPermit shall Is,doomed!
Code, must
funM1with comply wird such provisions or this pcnnit shall be dmmed rcvnked. ��r S L
� 7 BUILDING PEE.
CL7 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that thea is a construction lending agency for the perfarmance of
U O
he work for which this permit is issued(Sec.3097,Civ.C.) / ELECTRIC FEE
Isnders Name
ULender.Address QTY. _ MECHANICAL PERMIT' FEE PLUMBING FEE
UJ I cenity that I have mad this application and sate,that the above information is
coram, l agate to comply with all city and county ordinances and state laws relating a PERMIT ISSUANCE MECHANICAL FEE
building constronion,and hereby rumhoriu repeantatives of this city menter upon the
U Z above-mcmioned property for inspection imposes, ALTERORADDTOMECH. CONSTRUCTIONTAX
(We)agate to save,indemnify and keep hartnlecs the City of Cupertino against
Iiibiliiia.joh,roenntss.cccons mdeapensea which mayin any weyacerue agaimt said City AIR HANDLING UNIT(TO W."CFM)
e of
in<nnxqucnc—]111 "Y+^_l- LYg of this pemriL
4-5
_ AIR HANDLING UNIT(OVER 10,000 CFM)
S,mrcuf Ap l -VContechorr Date If EXHAUST HOOD(WIDUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I(0,000 BTU) Date Receipt#
Will the on.,wor
skin, handle hazardousmaterial
the nt
as Jcfincd by the Cupertino Municipal Cotle,Chapter 9.12,end the IlcAth and Safetyft�TAL:
(OVER W.fN1U BTU) TOT
Code.Section 25532(a)'1
El Y., 11 No I-AN RESID)
Will thcupplicamorfwurebuildingoccupamuseequipmenlordeviceswhichemitP(3HPOR IM,000 BTU) ISSUANCEDATE
hazardous air cnnmminums ns defined by the Bay Area Air Quality Munagemem
• .'t' TI COMP 100,000 BTU)
Lbuil ❑Yes ❑No IAL MUCH. SQ.FT.
ding
d the hazardous materials requirements under Chapter 695 of then � '
th&Safety Cade,Sections 25505,25533 and 25534. I understand thatT D
oes not currently have a tenant.that it is my responsibility to notify th<myuirtmenu which mon be met prior m issuan«of a CeniOcate ofar� - 41
n,agent DateTOTAL: (SSU CiJy�'
OFFICE qyV