25701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT rr:RMrr rvo. O
PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
B' GAD ESS: SANITARY NO. APPLICA'DON SUBMITTAL DAI
UNITa �p LOT# 'I sat,
OWNER NAME: PHONE JOPRACTOR'S NAME: IC NO: NIC CONTROLX
Q"t linr nL)S—S'4o
ARCHI I ECI7ENGINEER: LIC NO: ADRESS: ElcoNTACT: pNorye: QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M.z Ihereby affirm that l amlicensed underpmviaionsof Chaplar9(commendngwl JOB DESCRIPTION
+-TOOF fall move
and ofdivision Sof the Businnws and Professions Carr.and my license is in PANELS
pZu full...Clndeff«L
fZm Limmc Claws Lic.p UP TO 2W AMPS
m=y Date Come, 201-1000 AMPS
'ZOob ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
07 n p 1 understand my plans shall be used os public records.
r y F u10 SIGNS ELECTRICAL
Li,cosW Fund..innal
OWNER-BUILDER DECLARATION SPECW,CIRCUIT/MISC.
x c. 1 hereby affirm that I and exempt from the Convacmr's License law for the
w 3 a m following reason.(Section 7031.5.Business and Professions Code:Any cityor county TEMP.METER OR POLE INST.
I_'tS ON< which regains.wntditto construct,alter,improve,demolish,or lapse,any suncala
K�yTQ� prio,1.its icsiuner,also quires the applicant for such Permit o File a signed statement POWER DEVICES
ly C that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
ddpOO P,4 9oaomerem,with Section 7000)of Division Sof the Btomessond Professions Code) SWIMMING POOL ELECTRIC VALUATION
W=w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-
7>
Section 7031.5 by any applicant for a Permit subjects theapplicant o a civil FIXTURES
JecspenaltY.f
EO nm roam Nan five hundred dollars($500d.
C o ❑ I,asowneroOhc n NEW RESIDENTIAL ELELTR 5 .FT.
pmpehumisnerntendedcroferalforsalei(Solt compensation, Q STORIES TYPE CONSTRUCIIOt
y will dothssiums Code
fo,Contisnotintendede Law does of applye(See to an,Business
and nywhobu lds ori for,Contractor's License Law does not apply to an owner.(
own enywyees,provided onsuch improvements
denote tandad offerio thmughhls
employees,pf.videJtharvemmpis sold itsarcne year completion,
Torah r- OCC.GROUP RES.UNITS
however,the buildingsden of proving
is sold a within etr yearofcomplrtion,meowner- TOTAL: I
builder will have the burden of proving that he did net build m improve for puryose of ^ l
sale). TY. PLUMBING PERMIT11
'
❑ I.asownerofthep Openy,emenclusivelyconvactingwiihlimnmdcmn orsto Q E r eF1OO ZOO APN
mmmct the Projeet(Sec.OtH4,Business and Professions CodeP�he Conracon's ���\
Lwhocconders forsuchicense Lawdce notaMlymwownerofpropenywhobuildsarim thereon,end PERMIT ISSUANCE
J
projects with acontmrtor(s)licensedpumua Bothe Contractor's I
License Law. ALTER-DRAIN @ VENT-WATER EA) E YM IiOit�
nAl—
❑ 1 am exempt under Sec. B @ P C for Nis mason BACK FLOW PROTECT.DEVICE TSI
SANITARY N
Owner Dela DRAINS.FLOOR,ROOF,AREA, en"o I'a
WORKMAN COMPENSATION DECLARATION SCHOOL
Yry
❑ Ihcmby affirm thatlhavc a<crtifiwm of conxnno sdLinsure,oraccnificem of FIXTURES-PER TRAP RECLIFF
W.rkm'Cnmpcnsmi.n lnsurwce nraccnifiedcopy Nereof(5«.38W.Lab C.)which K FEE YN._
covers all employa's under this permit. GAS-EA.SYSTEM-1 INC.Eto
RECEIPT#Policy aBUILDING DIVISION FEES
Company GAS-FA.SYSI EM-OVER❑ Cenifml copy is hereby famished. CIIECK FEE❑ Certified copy is filed with the city inspection division. GREASEdNDUSTRL WASDING FEECERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAPS FEECOMPENSATION INSURANCE(This section need not be completed ifthe permit is forome hundred dollars($IW) SEWER-SANITARY-STORM EA.2GY FEE
or lcaJ
I certify that in the prefmmence of Nc work for which this permit is heated.I shall WATER HEATER WIVENT/ELECTR
of employ any person in any roamer so as to become subject to the Workers' PAID
z ACooutpervande Lawsof Califcaram Data WATER SYSTEM/IREATING Date Receipt#
z0 NOTICETO APPLICANT:If,after making Nis Cedificae of Esemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
P
lq hecnmcsubj«F1.the Worker's Compensation poovisionsofshe Labor CWe,you most
forthwith empty with such Provisions or Nis permit shall be droned revoked.
fY 7 BUIIAING FEE
LLJ (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for Ne performanu of
1..) the work far which this permit is issued(Sec.3W7,Civ.C.) T ELECTRIC FEE
Lende,is Name
ULetall Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify Nat I have mad Nis application and sure that the above information is
correct.l agree m comply with all city and count,.Nimamces and sum laws raboba to PERMIT ISSUANCE MECHANICAL FEE
F" building construction,and hereby amh°nss rep . (this city mender upon the
(„) uMwc-mrnii.nnl property
lbr innp«ti es.
CONSTRUCTION TAX
Z °"Pu ALTER OR ADD TO MECtI.
(We)ugrec t.save,indemnify and ep harmless N<Ci of Cupertino against
Ii:Nil.o.,I"udgmado.cosaa"dex yt way rosea mmusaid City AIR HANDLING UNIT p'010,000 CFM)
'If da ming
tI ^ AIR HANDLING UNIT 10,IXp CFM)
Signature of ApplicanUC am EXHAUSTHOOD(W/DUCT)
PAID
HAZk MATERIALSDISCLOSURE / HEATING UNIT(TO 100.00(BTU) Date R<ttipt#
Will the applicant or future budding occupant store or handle haasrdous material
as definW by the Cupertino Municipal CWe,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOO,OW BTU) OTAL:
Code.Section 25532(x)'!
❑Yes 11 No ft�HATIONIAN(IINGLERFSID)(SINGLERFSID)OR 100.0MBTU) ISSUANCE DATE
hassrdous air mntaminmu as defind bYtheBay AreaAir Quality Managcment
Die rdlo ER 1 W,00(1 RTU)❑Yea ❑No MECH. SQ.FT.1 have read the hautdous aratenals requirements under Chapter fi.95 oftheCalifornia Health@ Safety CWe ave-hewed.thtitis yn255M. (undersand NmIrthebuildingdocsmotments yhavessensr,et ois mysuanceiofa 1.entify the0uccupam of the requiremems which muss be met poor w issuantt of a C<rtificme ofI" A0
Occupancy. ',1g•�' I "1Ownrr or rathonecd a gam DamTOTA1: ' ^ ISSUEOD`89.^
OFFICE �4