25579 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I
ITY OF CUPERTINO BDB:DING-F,CEfTRI�AL PERMIT NO.
'APPLICATION/PERMIT PLUMBING-MECHANICAL 25579
BUILDING DIVISION BUILDING PROJECT IIIEN'I'IFIC,A'I'ION
ILDINGADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
('COMACT:
816 4IAN 61Tt Z_r UNTra or« / /
RS AME: PHONIi: CONTRACfOk'S NAMB: LIC NO: NM CONTROL
a"4, �TP.CY4,GINEER: LIC NO: ADDRESS:4i
PHONE: * - fir �T ` BUILDING PERMI'P INFO
QTY i$�:a#�TiAFI.,eCFRIC PERMIT" FEE
- BLDGCCf El PLUMB MECH
PERMIT ISSUANCEEl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IDBDPSCRIP
mdz I hereby al firm tum l am tic rotaltnderpmviaionaof Chapter 9(commencing with
HON
POOE Scala.7ow)of Division 3 of the Business and Pmfessiow CME.and my license is in PANELS
1a�yU full lereated elTwt.
LimoUP T020DAMPS
'
Q ZV yI
Limon Class Lic.p
y 6 s Date Contractor 201-1000 AMPS
1-yZN, ARCHITECT'S DECLARATION OVER IOOO AMPS
1�SIp1.1aI/��FLAOR pI"4.1
O Z y 1 understand my plans shall ba used M Public records. B II l,l U
W SIGNS ELECTRICAL LL VVV b L l 0 VVV
Q SN�dd S�S--,,� Licensed Profersional �/
ayU OWNER.RUILDER DECLARATION SPECIAL CIRCUIT/MISC. E al, GV
I hereby,affirm that 1 um exempt from the Ccommur's License law for the
Mwfollowingmann.(Section7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLEINST.
FI l'b l
fS�� which requires a permit m construct, impmve,demnlish.mr,epau any.tmnure DATE
f;!(T� prior to its issuance,also requires the applicant for such permit to file asigned statement POWER DEVICES
dC Qp Iltm he is licensed pursuannolhe provisions of the Convecmr's License haw(Chepwr SWIMMINGPOOLELECrRIC VALUATION
`1.T 9(commencing with Section 70PE)of Division 3 ofthe Business and PmfcsaionaCMe)
XWMm or that he is exempt Ncmfmm and the bmis for the alleged exemption.Any violation of FT
S OUTLETS-SWITCHES-FIXTURES
kZQ Scninn](IILS by any applicum fora permit suhjens the upplicantmacivil penWyM
SEG not more than five hundred dollars(5500). NEWRESIDEPMALELECIR . .
❑ Loseemerofthepro,"O.mmyemployees withwagecastbei...lecomprourinn, -SQ.FT. TYPE GQNS1RHCI'IQN
a3- will do the work,and the stmemre isnot intended or offered for sale(Sm.9014.Business
and Professions Code 'Me Commoner License Lew does not apply to an owner of
pmpedy It.moldsmimprovea,hemme,and whodoe.sucu work himselforthmughhis
employees,prnvidedtBm such improvemrnBerenotimendedmoffemdforsWe.If, OCC.GROUP RFS.UNITS
however.the building cer improvemem is sold within one yearof cnmplainndhe owner.
builder will have the burden of proving that he did not build or improve for purpose of
care.).
C] Las ownerot the properly,amexelusivcly contracting with limmsd mramemrs to QTY, PLUMBING PERMIT PRE FLOOD ZONE APN
consumer the project(Sec.9614.Business and Professions Code:)TTe Commerce. PERMIT ISSUANCE
License Law does not apply In be owner of pmpeny who bui Ids or improves thereon,and
whocontmas forsuch projects with amnnactor(a)licensed pursuant to the Contractors ALTER PA
License law. ALDRW ( ) FEE SUMMARY
❑ 1 am exempt under Sm, ,B A PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FRES
SANITARY Y N
Owner -Date- RECEIPTM
DRAINS-FhOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
❑ Ihemby affirm rhatlhav<a<mifmate of consenum xlGinsure,orecenificnm of - RECEIFT#
FIXTURES-1'ER'fRAP
Worketti Cnmpensminn ln.urancc orucenificd cnpylhercof(Sac.3800.Lab C.)which PARK FEE YN
covers all employee's undecthis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS R-CEIPI'g
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHF.CK FEE
❑ Certified copy is bereby furnished.
❑ Cer itiM copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'fRAP SOILS FEE
COMPENSATION INSURANCE
(This sm.m.,eed net lie completed if Ne permit is for one hundred dollars($IN) SEWER-SANITARY-STORM EA,200PT. ENERGY FEE
or less.)
I certify that in the pMumannereofthe work for which this permit is issued,l chall WATER HEATER W/VENT/ELECTR
not employ any perm.in any mmme,so as or became subject m the Worker' PAID
Cumpensarion Lawsof Califsmia. Dem WATER SYSIEMn REA'(ING Date Receipt#
O Z Applicant
z2 NOI IC17 TO APPLICANT:If,after making this Cmificamof Exemption,y ..omld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
fp become subject 9.the Workers Comjtenmticaprovim.m.fthe Lebo,Code,you most
5 forthwith comply with such provisions of this Permit shall be dimmed revoked. BUILDING FEE
6Wi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z I hereby affirm that them a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3090,Co.C.) I TOTAL: ELECTRIC FEF,
Lender's Name
F" Lender.Address QTY. - MECI IANICAL PERMIT I713E PLUMBING M.
0 O
IU I rectify Net 1 have read this application and state that the above information is
comet,l agmemcomply evitb.11 city andcoumymdicamer.rural lawsmhtingto PERMIT ISSUANCE MI',CHANICAL PEE
n'U building construction.and hereby authorize reprcunmtives ofthis city m enter upon the CONSIRUC'HONTAX to above-mentioned rt finspectionpurposes. ALTERORADDTOMECH.'
G z property al
rte to r e,indemnify and kmp har,nlev the Ciry of C p<ctino against
I M1ilitics,judg cal.c sa�p�%%�dem ch yin any way gninm dChy AIR HANDLING UNIT(TO 10.000 CFM)
Its m. I mn�t i.permit. .�s�t�
AIR HANDLING UNIT'(OVER IB,IgXI CI0v1)
Si amreaf, pll pCommnor pre EXHAUST IIOOD(W/DUCfT
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('10100,000 BTU) pate Receipt#
Will the plicanl or future building mcupanl stem or handle hvamoue material HEATING UNIT(OVER 100,0010 BTU) TAI:
as defined by the Cuper inm Municipal Code,Chapter 9.12,and the Health and Safety
CMe,Seemm 25532(.)?
Y. El Na VENTILATION PAN(SINGLE RFSID)
❑
ISSUANCE DATE
BOILER-COMP(311P OR 100,000 BTU)
Will theappliesrt m fumm huildingevropant useecuipmenr mdevices,licland,� R1 A O havatdous nit conami.ene,m defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r /1 .
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. SEP 2 3 1993
1 have read the harardous materials requirement.under Chapter 6.95 of the
Culifmmia Ilcnith&Safety GMc•.Sections 255.5,25537 enJ 25574. I understand that
occupant
gdoesnolncermt which must
be prior
my Issuance
of
tonotaft the .CITY UI- LUrtM IIY
cupunt of the reyviremana which muss be met prior to issuance of a Ccmificme of
Occupancy,
Owner m.athmized agent Data TOTAL: ISSUED BY:
OFFICE
1
i
17
J,,
18 6 Jfc1r�4 TE CT
avo
i
SEP0tDG 11V, 23 19 rIU
CIT of OF
D%pr4ftfi
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OFFICE PY /
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