25545 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BBILDT,Rf7—.F.IFCTRICAl. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25545
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: '/ . SANITARY NO. APPLICATION SUBMIITE.
111ALL DAT
.209 9%
�OLG� /Y �1�aVt UNIT LOT#
OWRS NA E: PIONE: CONI'RACI'OR'g NAME: LIC O:
y { NIC CONTROLS
2S .+f 8 - c C1,A, .0 5
ARCHITECT' . GINEER: LICNO: ADDRESS: n
h 2an 2a2ot7 w c / .�o�. COY6/7r
CONTACT: PHONE:
Q'fY. ETECTRIC PERMIT FEE BUILDING PERMIT INFO
D
PL
UM➢ 'MrCH
- I PERMIT ISSUANCE I J ❑
LICENSED(7ONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL EOR DESCRIPTIONIr
ptuyL Thereby affirm rhmlem licemt unaerprovismai of Chapter9(commencing with w
FOC Section 7000)of Division 3 of the Business and Professions Code,and my license Ls Ln PANELS
CUj full force and effect.
F'Z,p2 License Clues Lies UPT020TIAMPS
.<e- Data • Contract 201-1000 AMPS
Cz FO v=`Oi 7.a ARCHITECed.apC1.ARATION OVER IfgIlAMPS S RAREA E/SQ.IT.
sly
oz^ aerstana my pinnF Fn al naFed as anlareaa,aF I y
4 4slcrvs ELECTRICAL
E59 Licensed Rofess Doul
OWNERBUILDER DECLARATION SPECIAL CIRCUTUMISC.
X O
ex.
V 1 hereby affirm that 1 am exempt from the ConOnmods License Law for the
W�+u-vFi following reaua(Section 7031.5,Business and Furmaiare Cade:Any dry orcounty TEMP.METER OR POLE INST.
0.1 which mipermit ro emearacgalmr,improve,demdish,cur repair anyatrumure POWER DEVICES
N7 prior to its issuance,ulmm uima the applicant for such pennitto file a signed statement
y�j^ O that he is licensed pum...11.the provisions of the Contractors License Law(Chapter -
a p ' 9 pommencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
'^y orthm he is exempt herefmmana the basis for the alleged exemption.Any violation of PDXOUTLETS-SWITCHES-FIXTURES
i Section 7031.5byany.pplleant fora permit subjects dicitplicenfto.civil penalty of
G not more than five hundred dollars(5500). NCW RESIDENTIAL ELECIR S .Ff.
W m ❑ Lisownerofthepmpcny,ormycmployess with wagesntheirnolecomperuadon. Q TORIES TYPECONSTRUCTION
y will do thework,and the swnum ism,immndedorofferecifarsile(S..7041 Business
and Pmfes mors Code:The Commences License law does not apply to an owner of -
pmpertywhobuildsorimproves,hereon,and whodoes suchwoMs himselforthrough his
on employees,provided that such improvecntsarenot itnendedoroRered fnrsele.If. - OCC.GROUT' RES.UNI'T'S
homass
wever,the building nr Improvement is sc;dwithin oneycer ofeempletion,the owner- OT h
builder will have the Nmdcn of proving'that he did not build or improve for purpose of
❑ I,as awnerafthe pmpeny.cum exdusivelycanlre<tingwiNlicenW convacmnm QTY. PLUMBING PERMIT FEE ROOD ZONE APN
construct the Project(Sec.9014,Business,md Professions Cade)The Contractors
Licenu lawdoes notaWlymanownerofPrri whobuildsorimproveathereon,and PERMIT ISSUAN
jZ L7
whence Lo tafor such projectswitheconwmorta)licenced pursuantm,he Conmcmr's ALTER-DRAIN V{;N -
License law. FEE SUMMARY
❑ I nm exempt under gee. ,B&P C for this remon BACK PLOW PR CT.DEV C t "
v
SANITARY 'Y_N
Owner - Date RECEIPTS
WORKMAN COMPENSATION DECLARATION
DRAINS-FLOOR:ROOF.AREA,CON
00 TAX YN
EI Thereby affirm that l have a ttnificate ofcovent to Self-insure.or a certificate of RF.CEII'T#
FIXTURES ER TRA
Wmkes'Compenmrdnn Instararrttma<mifiedmpY,hereof(Sec.3g00,UDC.)which C - E YN
covers all employees iudcnhis pe.I,. GAS-RA.SYSTEM-1 INCA OUTLETS RECEIPT#
Policy BUILDING DMS FEES
Company_. GAS-PA.SYSTEM-OVER 41EA) PLANCFIFAK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with Ne city inspection division. GREASE/INDUSTRL WAS'ISI IN'TE'RCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This Faction peal not be completed ifthe Permit is foram hmtdred dollars($100) SEWER-SANITARY-STORM EA.201 ENIiRGY FEE
,Jr..)
I cereifythm in The performsnceof the work for which This Permit is issued,l shell WATER HEATER W/VENT/ELECTR
not employ any Peron in my manner so as to become subject to the Workers' PAID
z Compensatiomlawsof C.Hfomi.. Data WATER SYSTEM[FREATING a1;- Dale Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. I'O'TAL:
(/) become subject to he Worker's Compensation provisions of 0w Labor Cade,you..at
a ; foMwith comply with such Provisions or permit shill be demnea marked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC PER
z I hereby affirm that them is a construction lending agency for The performance of
V C) the work for which this permit is issued(Ses.3097,Civ.C.) TOTAL: ELECTRIC FEE
LL 5 lender's Name
resPLUMBING FEF.
t•' Lender's Adds QTY. MECUANICALITTMIT FEE
U I certify that I have read this application and state That the above information is
correct.lappet,to comply withill cisv andemintymemam,sandstate hwsn Aing to PERMITISSUANCE MF"CHANICALFEE
U Z uhnsengconsned pro,so herinsps tlonprcosexnta0veiof ddscirymcorer upon Ne CONSTRUCTION TAX
V uMrve-mentionedpropertyforimpwFnd keep
ALTER OR ADD TO M[CR,
(We)agree m save,indemnify and keep harmless The City of Cupertino against
1 hili'es,judgmems,ros,e and expen.Fs which may in anyway accrue against said Ciry AIR HANDLINGUNIT(TO 10.01LBC NE
uquence SOFT this pgm,it. - r
�9 AIR HANDLING UNIT(OVER 10,0010 CFM)
Signamreo Applicant Contractor Dme EXHAUST HOOD WMUCT, PAID
HAZARDOUS MATERIALS DISCLOSURE HFATING UNIT41'0 100,000 BTU) Date Ree
Will,m applicant or future building occupant Sale m handle hart door memrial 1IEATING UNIT(OVER 11,000 BM TOTAL:
as defined by the Cupenina Municipal Cast,Chapter 9.12,and the liewth and Safety
Code,Section 25532(a)T
VEND RATION PAN(SINGLE RBSID)
❑Yes ❑No
BOILER-COMP(311POR Hat BTU) ISSUANCE.DA E
Will the applicant or furore buildingoccupanr use equipmentordeviceswhichemit h
hauum doair contaminants as defined by the Buy Amu Air Quality Management .BOILER.COMP(OVER 100,000 RTU) P '
Oktnct7
❑ SEP 14
Yes ❑No NEW RESNTI
IDEAL MGCH. SQ.FT.
1 base rad the moudous mmedals ne uimmenta under Chapter 6.95 of the a
Culifomia Health&Sufe,y CMF,Sections25505,25533 an a 25534. 1 understand that _ Ciry V�
^— if the building dins not currently have a tenant,that it is my responsibility mnmify the V!-��\�yl�/�1����p1��y
mevupunt of the requirements welch most be met prior to issuance ofit Certificum of -�/ //V t
Occupancy. J
Ownc,or aulhmixed.,Far Dme TOTAL": ISSUED Ely
OFFICE
• 2!1 1 1 _ °ERN jNSPECTICH'n TIVITY HIR PERMIT"i 2a,4s -
20F U
it MAIN-Ul.
•,
• INSPECT?G�1 CATEGCRY 101 b
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jNSPc--'TMN CATEGCiY 205. . •
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• INSFECTION CATEGORY 11
•
DATE SINE TYPE !:t ?„_PEC TION MISPECTGR ME ? ; a:ONNENT
• 1ii14143 - SHEETR1' '3 •
I' • ?r'SP ET : 1_ _ c..' •
• DATE PC= _ TFE-Cc.ii ° TION o PTf6 °RrE FFF. ' CGFliiENTG _--
11 231° a. '," LATIR IV_
• iN3PECiIG "TE120 Y -114 �� �S� •
DATE DGd TNFE C FN �TIGN . nnPECTOR ODE 01, �FlMir- S
• 11,12 /°i CRAr_:# '_CriT _ - :��l_ - o .
• INSPH_TIC1 CaTE6Cfi'r 315
• 'ATE OONIF TYPE OF IM FUTION INSPECTOR COC F'.IF CCi E11 E:
1 ;1115;93 ROOF NAIL 1V F
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Rt lt'.J nuur ,rtH tHh '.J .dY _
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%u L i 1UN _HIU3 61 J11 _
ATE _;ONE TYPE OF INSPECTION INSPECTOR CODE PIF COM ENT3.
U ltif7i rcnM l Mr-LIIUN H611411I rUA rth. 1 4 GD342
• R)S4 JOLLYMAN LN,
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_PATE .,tk' TYPE OF INSPECTION INSPECTLIIK ODE 3F ' "_OMn s
IN>P=CTION CATEGORY 555
' ,ONE TYlP OF INSPECTION IBSPECTOa COuE f. I:TE.
11x`37?"Y3 81D0 FINA'
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