25300APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO
O 1,111N -8LIZ"1'R1 AL
PERMIT NO,
APPLICATION/PERMIT
MECHANICAL
PING
BUILDING DIVISION
I11111.IJING PROJECT IUEN'1'IN'ICA'1'1(3N
PROJBINGECT
25300
jIUILDING AD/DRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
it ✓GW 1 6 LC, 0
UNIT# LOT#
l�►S/Q J
O NBRSN Mli: PHONE: -
NT�('ACT'OR'S NAh1E: LIC NO:
NIC
CONTROLM
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M sect
ARCfII'I.Ct' HNEER: LIC NO: A KESS: 'y
I
L! Z UCVjK O e—
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CONTACT: - PHONE:
QT'Y. ELECTRIC PEAMI'1'
•eE
BUILDING PERMIT INFO
ELECT PLUMB MECII
PERMIT ISSUANCE.
❑ ❑ 0
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
I hereby affirm that I am licensedandcrpmvisions of Chapter9 (commencing with
Section TIDO) of Division 3 of the Business and professions Code, and my license is in
PANELS
"Teo 'C
fill fame ant) effect.
(h�JS
Liccnu Cl ss Lie.#
UPT02MAM '
-J
:rte Comma
201 - 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
ARCHITECTS DECLARA N OVERI"AMPSIF
I understunA my plans shall be uveJ ta puMlc reen Js.
'
SIGNS ELECTRICAL,
LlcevecJ Prolcssitnal
OWNER -BUIL)
SPECIAL CIRCUIT/MIS
to. th Contractors License Law for the
1 hereby affirm that I am exempt from the Caston
r
'TEMP.
C'v
following reason. (Seaton ]031... Business and Professions Code: Any city or county
MISTER OR .E INS T.p'
which requires n permit alteL improve demolish, repair strutters
poortois , also re uiresthe pevniuo file ed statement
for suchthe
POWER DEVICES �
nummunt to the prvisiosocant
licensed Co License Lo
that he is licensed pursuant m the provisions of the License Law (Chapter
(Chei
9(rommencing with Section](10o)of Oivisinn3nf the BusinasanJ professions Code)
the Bmineva
or Matt he is cxempuherefromund the basis lot thealleged e.cmp rte. Any vmhnionnf
SWIMMING POOL ELECTRIC
VALUATION
�90
703 L5 by any applicant for a permit subjects the applicant m a civil penalty of
OIITLLTS-SWITCHES-FIXTURES
�06dSection
not more than five hundred dollars t$500).
❑ I,Mowneraftbepmo any,ormyemplaymswiNwagmasthcirsolecompensation,—SQ,STORIES
NEW RFSIUENTIAL ELECIAFT.
TYPI:CONSTRUCTION
will do the work, and the structure is not intended moffeml for sale(Sec. 7044, Business
and Professions Code: The Confiscates License Law does not apply to am owner of
r
property who builds nr improves flumen, and whodoes such workhimselt orthmugh his
employees,providedmprovehimpmv arenas tendedmtffertd far ole.
OCC.GROUP
RFS. UNITS
r.
soldofc the owner-
improvement didnone
however, ihe wit
TOl'AL:
t byear
llhave the burden prove fo,
builder will hove she burden of proving ohm he did not build or improve for purpnu of
le.).
❑ I, as owmerofthe property, ameacluslvelycontocaing with licensed contractomn
QTY. PLUMBING PERMIT
PGE
FLOOD ZONE
APN
onsmmt The project (Sec, 7044, Business and prafammus Code:) no Contractor's
License Law rims nm apply to on owner o(pmpe rty w ho builds m i mpmves there..... d
PLRMD' ISSUANCE
whnerniacts for such projects with a mnfractof(s) licensed pursuant to the Communes
License Law.
ALTER - DRAIN&V[NT - WATER (PA)
FEE SUMMARY
❑ I am exmnpt under Sec. P & P C (or thio reason
I3AG C f: ICI:
OUTSIUFL
SANITARY Y. N
.
Owner Data
DRAT S-P.O RR is OFA N
RECEIPT#
SCHOOL TA% Y N
WORKMAN COMPENSATION DRCLARATION
❑ Thereby affirm fhatl haveacenificate of consenno self -insure, oreccrtifieme of
IIXTI _
RECEIPT#
PARK FEL: Y_N
Wuhcui Campensmion lnsurencwrattrtificdcopy thereof (Sec.3g00, UubCJ which
mvcrs all employee'. under this permit.
AS - PA. Y -1 INC. . S
RECEIPTp
BUILDING DIVISION FEES
Policy
421,
Company-
. SYSTIiM-
PfANCIIECK FEE
C]Certifiedcopyish ndryfumishW.
GRADING HE
❑ Ceniftcul ropy is filed with The city inspection division. GREASFANDUSTRI. WASTE INTERCEPTOR
CERt'IFlCATE OF EXEMPTION FROM WORKERS'
GRFASHI RAP
SOILS FEB
COMPINSATION INSURANCE
ENERGY ME
(This section need not he completed ifahe permit is foronehundrM dollars SEWER - SANITARY - STORM EA. 200FE
or less.)
I certify that into, perfoarnmer ffhe work far which thin permit is issued, l shall WATER HEATER W/VENT/HLECTR
not employ any person in any manner ser as to become subject to the Worker%
PAID
Compmsmmnlawsof C.Jffmau. Date
WATER SYSTEM/IREATING
Data Receiptp
Applicant
NOTICEI0 APPLICANT: If, after mokingthis Certificare of Exemption, you should
NEWRESIDENTIALPL.MB. SQ. FT.
TOTAL:
become subject on the Worker's Compensation provisions of the labor Core, you must
forthwith comply with such provisions or this permit shall be, deemed revoked.
BUILDING FEE �#
SEISMIC RE.
CONSTRUCTION LENDING AGENCY
L hereby affirm that there is a construction Lending agency for the Performance of
ELECTRIC FEE
thewmk furwhich thispermit isissued(SecAN7.Civ.CJ TOTAL:
Lcriders Name
Lenders Address
QTY. MFCIIANICALPERMIT
FEE
PLUMBING FEE
1 certify that I have real this application and state that the above information is
correct. ingrec mcomply wish allciayand wunry oNinences sad xmm lawuelating to
FERMI IASSUANCE
MECHANICAL. FEE,
building construction, and hereby amhodu representatives of this city to enter upon the
CONSTRUCDON TAX
ab
above-mentioned pmIsmy for inspection purposes. ALTER OR ADD TO MSCI I.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmcnts,costs and expenses which may in my way seems against said City
AIR HANDLING UNIT(TO I O," CFM)
in comeyueace of the famati ng of this permit.
r, L'7
AIR HANDLING UNIT(OVER I0,000 CFM)
Simmons of Applicant/Cory acmrr D.—M EXHAUST HOOD(W/DUCI)
PAID
Y,//
[ZOOS MA Z IALS DISCLOSURE
HEATING UNIT (TO 100,0010 BTU)
Date Ra ipt #
Will Tho uppli..nua future huilding mcupant more Or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
Code, Srcti 25532(a)P
❑
El Yes El No
VENTILATION FAN (SINGLE RFSID)
.�
ISSUANCE DATE
BOILER - COMP f3HP OR I f f" BTU)
Will to building equipment malitiesanagement
it contaminants as by the
haztrict? air conmminams ns defined by the Boy Area Air Quality Management
BOILER - COMP(OVER 100,000 BTU)
District?
,
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. Fr.
f1 p
I_
1 have read she hazardous materials rcquim mems under Chapter 6.95 of th<
California Health & Safety Code, Sections 25505, 25533 sad 25534. 1 understand that
n
nob Curren, ly have a tenant, That it is my respumbility to notify the
he huilding docseq
JULif ate' -
oreopunt of the requirements which must be mea prior To issuance of a Certificate of
H/
VX
Occupancy.
ISSUED BY: ` 1
Owner orauthmizedagem Date TOTAL:
OFFICE