25846APPLICANT TO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO HUI(AINU.ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION'
PERMITNO.
25846
HUILDII�,y1JDRCS'S: , � UNIT# LOT#
•'V{\' /�,17A-•'••`,'
SANITARY NO.
AI'PLICA'I'ION SUBMITTAL DATE
OW PHONE:
CONTR O' P LIC NO:
NIC
❑
CONTROL#
IARCHITECDENGINFER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PP.R I FEB
BUILDING PERMIT INFO
BLDG ELy+CI' PLUMB MECH
BLD �Jr/_�Y\/ 11 1:1
•
PERMIT ISSUANCE _—
LICENSED CONTRACTOR'S DECLARATION
Ihemb affirm that l am licensed under
Y Provisiovions Cote, and mmencise with
Section 700o) of Division3nf the Business and Professions Cale, end my license is in
APPLIANCES- PSI AL
PANELfall ,
JOB DESCRIPTION
effect.
ficarnse
��
Lc
I Llmnao Clusx Lich
Clas
O AMPS
Data ConWcm�
11 000 AMPS "
ARCHITECTS DECLARATION
1 understand my plum shall be used m public meards. �.•'
ER 1000 AMP
SQ. FT. FLOOR AREA
E/SQ. FT.
SIGNS ELE RI(
Licensed l'mfcssionnl
.1'E 1 I'I'/MI
DER EC ARAI ON
that I of exemptto.. Contra Low for the
I hereby .,firm 0m I am exempt from the Contractor's e. Any
following remora (Sttfion ]W stru t. aincsa and improve,
Cale: Any ciry o Oren.
which de io demolish, anysauaum
l imlmme,demolish, ore
mris
p
:t. METER POLE IN T
r 1
thealcor,
itsisssnPermit
penniuoLiease
sig stummmr
requ the
pdonnssicensed fthe
OWER DEVICES I�
bbb 11 V
pals.
Pr visio s Co
that he is transact pursuant to the provisions of the Coovactnr's License Low (Chapter
La
exempt tlleedexeatio.Any a lona Code)'
adthe
•WINNING POOL ELECEN S I
VAI UI�'&l
isbasislcan the
or he is exempt therefrom and the basis for the alleged exemption.isilperadlyof
thattherefrom
for a permit subjttts the applicant ... ivil penalty of
not mo than by a hundred
not momthanfivehepin dollars(4500).
❑ I,mownsofNeprnocconermyemoordedwithwed formleimole70 Btamion,
will dmhewurk, end the
orsLicese
iV�—
O
STO ES TYPE CONSTRUCTION
J
OU'T'LETS-SWITCHES-FIXTID
' Li�T
NEWRESIDEMDALELECR 5 .FT.
Q
La docarmle(SIy1.an.nrrsa
and Professions Code: The Cnmractor's License Law does nm apply m an owner of
he Contractors
'
properly whobuildsor improves themomand whadoes such work himselforthroughhis
own employees, providcdthrt such improvementaam not intendedoroffercd forsale. IL
-
OCC. GROUP
BF.UNITS
T T �
however, the building orimprovcment is mid within one yearo(completion, theowner-
builder will have the burden cf proving thot he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
❑ I,usnwnernnhepmperty,omexclusivelycntracring with licaumdennoamo.. to
I+I.ODD ZONE
APN
construct the project (Sec. nwq Business and Professions Cade:) The Contractor's
Litems law does not apply to an owner.(property who builds or improves income, and
PERMIT ISSUANCE
who commas forsuch projects with aconrsucta(s) licensed pursuanttothe Contractors
License Law.
p1 TER-DRAIN&VENT-WATER (PA)
FEE SUMMARY
❑ I nm exempt under Sec. , B M P C for this reason
14ACK FLOW PROTECT. DEVICE
1 l H " I
SANITARY YN
RECEIPT#
Owner Do[,—URAINS
- FLOOR, ROOF, ARPA, GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Thereby offimr that l have a certificate odcoment an self-imure, or a certificate of
Workers'Cnmpensation lnsumnce oracenifieJ copy thereof (Sm.7AW, Lab CJ which
RECEIP #
FIXTURES - PER TRAP
PA Lr Y N
en all nnployee's unAer @is permit
Policy #
GAS -EA. SYS'1'1?M-I INC.40U]LIi],S
RECEIPTp
BUILDING DIVISION FEES
cry
GAS- EA. SYSTEM.OVER 4(FA)
'E
rll0ed copy is hereby famished.
GRP.ASEIINDUSTRL WASTE INTERCEPTOR+CERTIFICATE
Codified copy is fled with the ciry inspection division.
OF EXEMPT ION FROM WORKERS,
INSURANCE(This
GREASETRAPCOMPENSATION
SEWER-SAMIARY-STORM E�A. 2WFT.
section need not lK completed ifthe permit is for one hundred doll I$Ha)
carless.)
WATER HEATER W/VENDELEMRnt
I cenlf,,h.t in the perfmmence of the weak for whichthis permit is issued,) shall
employ any Tarso in any nraemer as ea m become subject m the Workers'
CELEMICME
WATER SYSTHIPTREATING
Cnmpenaidon LawsofCulifaniu. Dale
te Receipt#ApplicumNOTICETO
APPLICANf:IC.Her making this Cmtificale of Exemption, you should
NEW RESIDIEMAL PLMB. 'SQ. IR.TOTAL'.become
subject to the Workers Compensation pnwisions of the labor Code, you must
fortwith comply with such pmvisiona ar this permit th.11 be deemed revokM.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
IxnEers Name
TOTAL:
�•
Landers Andmsx
QTY. MECHANICALPERMIT FTE
PLUMBING FEE
I certify that 1 have read this application and state that the above informmion is
correct. l agree m comply with all city and eca tcy ordinances and state laws relating to
PERMITISSUANCR ,
MECHANICAL. TEP.
building construction, and hereby authorize representatives of this city re enter upon the
above-mentioned propcdy for inspection pue,asom.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(Weda0m, Viase, indemnify and kap harmless the City if Cupord...ga cut
liabilities,' na.comaaa hichmayln any way accrue againstmid Ciry
W
AIR HANDLING UNIT CFO 10,OCFM)
Inca y race if, ting of this perm .
AIR HANDLING UNIT (OVER I1LBIlJ CPM)
r mmol Applica unCenrrecmr Date
17XHAUST HOOD(W/DUCD
PAID
HEATINGUNIT(TO I00,0110RTI1)
HAZARDOUS MATERIALS DISCLOSU E
Date Rttelpt
Will the ran Cupertino Mubupdingoem haptermnrh Alh HealthandS feta
define)io ran nn Municipal Cale, Chapter 9,12, 1 the Heehh and Safety
IOTA
TRSATING UNIT (OVER IOO,Ig10 fl'I U)
VENTILATION VAN (SINGLE RISID)
Cr
Cale, Section 25532de)P -
❑ Yes 13 No
Will rheapplicanr ar (muco builJingoecupam use equipment ordevicuwhichemit
BOILER - COMP OHP OR 100,00d BTU)
ISSUANCE DATE
hnzyMoua to, cnmaminunts us defined by the Bay Are. Air Quality Management
District?
Ycs ❑ No
El Yr,
•HOII PR -COMP (OVER I W,fXX) if] U)
_
A' 0
NEW RESIDP.NTIAI. H. MECSQ. FT.
of the
1 have mad the licSoftly
mations 3505,25533reeprionowmunder Cheerer understand
California I Icalrh &Safety Code, Sections 255(15.25533 and 25574. I undersmnJ thm
if the h tilding Awa no, currently have a tenant. that it is my m.,panaihility to ramify the
DEC'
occupant of the requirements which must be met prim to issuance of a Cenifeate of
Occupancy,
IIIIVU
ISSUED HY:
Owner or nmhorizcd .,carDate
TOTAL:
OFFICE