25935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '.ELLUIR PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL !�5 /\
BUILDING DIVISION BUILDING PROJECT]DEN'1'IFIOAI ION G J 3 J
BUILDING ?ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
V kat IS �� ed • UNIT# LOT#OWN
—All
NAME.Mae O_l n PHONE C._ 062/ CO�RnACT.Go NAME:FAtr xe LICONO: N/C CONI'ROLN
so
\RCIIITECDENGINEER: 2( LLIC NO: AD S: ❑
6SIN0/!L!e �"!. ,C1v�2654,v /LL. G
CONTAc: �(��PJHON/E::I��J �J(� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
M/41'GtRL /}tpflLGo Cj d / /Q 7 1 BLDG EL PLUMBMECH
PERMIT ISSUANCE /TY
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
❑a'Z I hereby affirm that T am licensed underprovisionsid Chapter9(commencing with
'-100 Senior7").fDivision Sof the Business and Professions Code.and my because is in PANELS
wwLLI of L a loose xa clmJ effect ''ll ry('��� �
. nu Class Lac.# Y7 BOf„T#-J UPl'0200AMP5
yr 6 Date Contractor 201-1000 AMPS
f—yZ ARCHTTFCTS DECLARATION SQ.FT.FLO RARER S/SQ.FT.
OVER ELECTRICAL AMPS w
01—M I undersand.,,[am shell be used as public rccmds. ['`LJ Jk
P-1?F'; SIGNS ELECTRICAL
y�.J Inamcd Przdessleast
=W< OWNER-BUILDER DECLARATION SPECIAL CIRCUEUMISC.
kOc. I brachy affirm that I am exempt from the Contractor's License Law for Ne
a O , following reason.(Section]0315.Business and Professions Cods:Any city or county TEMP.METER OR POLE INST.
�.y; which requires a permit to construe,alma,improve,demolish,or repair any s(Nnllm
WWY2 Priori()its issuance,also requires Ne applicant for such Permit o fit"signed sentiment POWER DEVICES
,=<0 That he is licensed pmmarom the prssnsaons of the Convectors License law(Chapter
a Ko� 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRICVALUATION
mm or that he is exempt therefrom and the basis for alleged exemption.Any violation o OIITLEfS-$WITCHFS�
I_Z Q Section 7031.5 by any appli<wt for a permit subjects the applicant m a civil penalty of FIXTURES /'1 t —n
5�Q mol marc than five hundred dollars($500). —6
ec o ❑ I,mowtmroftheprmceny,orm em to aswiO wages mtheirsolecom NEW RESIDENTIALELECIR _SQ.FT.
Y P Y g censat ass STORI: TYPE CONSTRUCTION
LB— will dofesions and the he Coeasnotter's Licenseended offeredfor
no,safe
toa4,Business
and Professions Cade:The yes thenors License Law does not apply to an owner of _
pmpenywho
yeer.,Jsorimproveeth improvements
doessucerade oroffifor throughhis 1
employees.provideJ that suchimprovements erenotantended oroffeaed forsalc.If, OC ;9R P y AS.UNITS
however,the building or improvement is sold within one year ofcompletion,the owner- T t '�' L., 4
builder will have the burden of proving that he did not build or improve for purpose of xn'
.ala). QTY. PLUMBING PERMIT a '`I
❑ hct the prafthe ject(See.70,1. exclusivelycommasimis Cle:)Tdcommeotsm hS F O ,ON - IAPN
mnmet the project(Sat.TD44,Business and ywho build Code:)The Contractor's s)7"t�, Jill
License Law dcexnot Projects
witha rnfproceny whosed Pumimpmves thrtwn,md PERMIT ISSUANCE ', �-- DAT
who seLaes for sac-project withmmntmeorts)licenced Pursuant to Contractors
Lactase La, ALTER DRAIN&VENT-WATER(EA) FEE SUMMARY
[3I nm cxnnpt under Sec. ,B&P C far Nis reawn BACK FLOW PROTECT.DEVICE OIJI'.SID:FEES
SANITARY y N
Owner Dem DRAINS-FLOOR,ROOK AREA,CONE, RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Yry__
1 hereby affirm that I have a certificate of camsentto sel6insum,or a Oubliette of
urkers'Compenxaim loomeareemn anifiedcopys curaf(See.390),Lab CJ which FIXTURES-PER TRAP RECEIPT#
PARK FEE YN
esters all empluyefx under this cemit
t . GAS-EA,SYSTEM-1 INC.40UTLETS RECEIPT#
Policy# BUILDING DIV ISI IS
Company
❑ Cenifiedcopy ishembyfumishW. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ccnified copy is fled with thecity inspection division. GREASHANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE �+
COMPENSATION INSURANCE
(This section need not h completed ifthe permit is for one hundred dollars(SI00) SEWER-SANITARY-STORM EA.20oFT.
or Jr..) ENERGY FEE
Imnify that in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Parson in any manner so as to become subject an the Worker% PAID
z Comt -Laws of Cnlifomiu. Date WATER SYSTEM/IREATING Dam
Applicant z 0 NOTICE TO APPLICAM':If,after making this CcOlicam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
F^ ` become subject tp dm Workers Compensation provisions ofthe labor CWr,you must TOTAL:
CL > forthwith comply with such provisions or this Permit shall bedamul revoked. BUILDING FEE
a z CONSTRUCTION LENDING AGENCY SEISMIC FEE ISI
th
1 hemby affirm at there is a construction lending agency for she performance of ll
U O the work for which this .it is issued pies.3097,Civ.CJ ELECTRIC TEE
U. Landers Name
O L) Lendre,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEB:
1 certify that 1 have read this application and sive thm On,above infmarmion is
F0.Wi rorecL I-I—nm comply with all cityanJ county mductees and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction,end hembyauthodm teprea eadvesafthis,by to inter upon the
V ahovememaowd progeny Por inspection purposes. ALTER OR ADD TO MECH. CONSTRUCIONTAX
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabilities,judgmer,costs and expenses which may many way ucearamrialsaid Cary AIR HANDLING UNIT(TO 10,(100CFM)
Ln
qucnaof Negmntango dg,permit.
2_] A AIR HANDLING UNIT(OVER I0.000CFM)
Signalmatin Applicant/Coulencmr AV6L Da EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000)BTU) Date Receipt#
will the applicant or future building occupant score or handle hazardous material
as defined by the Cu,mim Municipal Code,Chapter 9.12,and the IIcahn and Safety HEATING UNIT(OVER 100,000 BTU) TOTALCods,Section 25532bm?
❑Yes No VENTILATION FAN(SINGLE RISID)
Will the applicamorfufutum building oemp:mt useequipmetn tar Jeviceswbicharm BOILER-COMP f3HP OR 100,(100 BTU) ISSUANCE DATE
acolous air contaminants as defined by the Bay Area Air Quality Mmagemem BOILGR-
D swim? COMP(OVER 100,000 BTU)
,. ❑Yes 4T No NEW RESIDENTIAL MECH. SQ.FT. (�
x'" .4 1
ID
1 have read the hazardous mumdals nap aremcros under Chapter 6,95 of the
California l leakh&Safety Code.Stations 25505,25533 and 25534. 1 understand Out
if the building(Idesmocmrattly have amnam,date itas mysuanceailaryto enotify the
if pant f the es not cur Les which otpst be tact prior m issuance of it Certificate he
Orrnpa
,\�Owneror audismoreda enself ISSUED BY: j))-(�
OFFI