25081 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO DD°:Dw'i IdlcI.11AL PERMIT No. 2Q'�,
APPLICATION/PERMIT PLGMBING-MECHANICAL. �O
BUILDING DIVISION BUILDING PROJEC7P IDENTIFICATION L �!
BUILDING ADDRESS: ,yf1 SANITARY NO. APPLICATION SUBMITTAL DATE
1&ISO J Ames4O W A_J` If— UNITg LOT# S �I l-7 3
OWNERS NAME.: PHONE: CONI'RACVR'S NAME: LIC NO:
„ IDN I, ,$( tlf 1_ N/C COM'ROLg
' .ARCH ECTANGINEI3R: LIC NO: `-Q�' �Z A
EJ
CONTACT:. PHONIC: �
QTY. - ELECOUC PERMIT FEE NUILCT PERMITINFO
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE O 11 %I 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION
pqy Ihereby affirm ilia l am licensed underprovisionaofChapter9(commencing with
Paco Seedlmm]IXNB of Uivieion Sof tppBuainwe end Prnfeasinns Cnde.and my liansa iv in PANELS a
q.V F full force and eft G 9D
F=W License Chis Lica I SI`— UPTO2WAMN
m Q°' Dam Cnmmcmr 201-I"AMPS !J
F'rn� ARCHITECTS DI RAT NQ.IT.FLOORAREA ' $/Q'.
OVER 1000 AMPS
Z'Gr 0 1 underitwtJ by plans shall be used as public records.
P.'vrS JWJ SIGNS ELECTRICAL
Zi
2n Licensed I'rofessionul
aa�y�Q dust
lam-BUILDERmDECLARATION SPECIAL CBiCUTT/MISC.
W 3 LLy 1 hereby nflltm that 1 ant exempt from the Commmnrs License Law rot rhe '
following remnn.(Section 7011.5,Business and Professions Cade:Any city me...I, TEMP.METER OR POLE NST.
�0� which requires a permit to construct,alreq improve,demolish,or repair any structure
}� prior to its issuance,also tenures the applicant for each permit to fhleasignsol aament POWER DEVICES
Wcup That he is licensed pursuumt to the provisions ofthe Contractor's License l<w(a." JTVYTi
0.tT5�o�' 9(commencingwith Section]000)nf Oivisinn Jaf rhe Businasand Profasi.naCMe) SWIMMING POOL ELECTRIC7FFE �00D
LUA ION
W_m or that heiscxempltherefromand the bssisfor the allegedexemption.Any violation of OUTLETS-SWITCHBS-PIXTVR9�
Section 7031.5 by any applicant for a plural subjeca the applicant toe civil penalty of
s 20
nod more than five hundred dollars($500). NEW RESIDEM]AL ELECIR S .FT.
q' Co ❑ I,00wnerofihepro any,ormyempdoyeeswithwagesastheirsolecomp.n.n. n, QORIES TYPE CONSTRUCTION
tq will do the work,and Ste strandmisamimendedoroffered formle(Sea 7044,Busness
and Professions Code- Die Contractor's License Law does not apply to an owner of
propertywh.ladidsmimpmves thereon,and whodoessuch work himselforthroughhis OCC GROUP RES.UNITS
wnemployees,proviled that,mch impr.ventems are ant intended proffered innate.IL
however,the buildingor improvement is sold withinome year ofcompledom,the owner. 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
valei).
❑ Las ownerol die property,ant exclusively connecting with licensed contractors m QT'Y. PLUMBING PERMIT ZONE APN
construct the project(Sec.7044,Business and Professions Coded The C.carmar S
pEliMl'1'ISSUANCE
Licensel.awlcesnor applymanowner ofprepeny whobuildaorimpmvesthertnn,end (/U
wheLamsferauch projwrswithecomraednr(x)licensed pununntaahe Cmmmcmr'a ALUM DRAIN VENT.WATER HIA)
Licenmu Law. PEE SUMMARY
❑ 1 em exempt under gee. ,B&P C for this meson BACK FLOW PROTECT.DEVIC17 SANITARY Y N
Owner —Date— pRAINS•FLOOR,RIx]F,AREA,CONU. RECI,IPTa
-WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
EIIherchy ulRmt tbarl hove acenificam ofcumenuo mlLinsurt,oraanifimm of FIXTURES P17R TRAP /)0 RECEIPT.
Wmke Compcnsutionlnsurancenracenifiedeoythercof(S..JSW,LebCJwhich PARKFEE Y N
covers all employee's under this permit. GAS-EA.SYS'1RM-I INC.4 OUTLETS .3a DQ RECF.IPTa
Policy a BUILDING DIVISION FEES
Cotnpeny- Cf �^' j'�s-. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ITE
❑ Certified copy is hereby furaisnW.
§' Certified copy is filed with Ne city inspection division. GRFASPANDUSTRL WASTE INTERCEPTOR GRADING FIX
CERTIFICATE Oil RXIBsI ION FROM WORKERS GREASF.TRAP SOILS PEE
COMPENSATION INSURANCE
IT hisseckstiadl not becompleted ifnbepsond is femme hundred dollars($100) SEWER-SANITARY-STORM EA.2001717. ENERGY FEE
or less.)
I rectify thv in the performance of the work for which this permit is issued,l shall WATER HPA'TERWIVENT/ELECTR
not employ any Person in any manner so as to become subject to the Workers' PAID
z Cmmpansation Lawsmf Celifomie. DateWATER SYS]'EM/1'R13A'DNG Dae Receipt
Applicant
z C NO]ICE TO APPLICANT:ILaBer making this Certificate of Exempti.....should NEW RESIDENT IAL PLMEL SQ.Pr'. TOTAL:
Pr4 became subject o the Worked's Compensation Provisions ofthe Labor Code,you must
C4 7 forthwith comply with.ucn provisions or,this pectin a hall be deemed revoked. BUILDING FEE
Uj...r Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby effitm than there is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ME
Leader's Name
OU a ITE
Lender'.Address QTY. MECHANICAL PERMIT' PEE PLUMBING O 0
U I certify than I have mad ON application it state that the above information is
coven,degree to wmply with all city unA county ordinances anA nate laws rtlaingm PERMIT ISSUANCE MECHANICAL FEE
UI•"a ti building construction,and hereby authorrze representatives ofihis city mender upon the CONSTRUCTION TAX
7 above-mentioned property for inspection purposes. ALTER OR ADD 10 MECIL
G (We)agree altruist,indemnify and keep hnmless the City of Cupertino.,ma t
liabilities,judgmenca,costsand expenses which may in any way secrucagaind said City AIR HANDLING UNIT CTO IO,I]EO CI'M)
in consequence of4hegroolingro�f thhiiisss pe�mt/tJJJ[��I.
M//. LJIIM�I —C/I 7A 3 AIR HANDLING UNIT(OVER If."CPM) .
Viature of ikirpicard,confroccor Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATIdUAIS DISCLOSURE. HEATING UNIT(TO IWWO BT Of Date Rueipha
Will the applicant or fume building occupant smrc or handle hazardous maenad
t.defined byrhe Caliendo.Municipal Code,Chapter 9.12,and the Health ad Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: ;z. DU
Cale,Section25532(e)?
0 Yes ❑No
VENTILATION PAN(SINGLE RESID)
WilltheaMlic orfutumbuildingwcupmt useequipment mdevices whichemit BOILER-COMP TIIP OR IMPOSE BTU) !0UKGEl)ATE
hazunl.us air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) ���� {vJ
Divided? 'I 'j �
❑Yes ❑Nu NEW RESIDENTIAL MECFL SQ.Pr'. MAY 17 1194o
1 have mad the hazardous mamrlals requirements under Chapter 6.95 of the
Cali6mia HealOh&Safety CMM,Sechions25505,25533und25534. 1understund Wm C1 Ur.aVUfrrT lJwv
if the building does not currently have a motor,that it is my responsibility to notify the
Ocupof the requirements which must Fe mel prior no issuance of a Certificate of
ccupancy. SII I_ �y"�
'
Ownerornuthmized agent Dom TOTAL: ISSUED BY: `t `O • LifC Ir