25317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B➢D,MTTI'F,CTRH]A' PERMIT NO. /� f�/�
APPLICATION/PERMIT PIUMB N
NGPROJECT IICHANIFIC /5 ,( �I 7
IIUILDINfi DIVISION BUILDING PROJECT IDFN'III9CA'f]ON L lJ d 1 I
BUILOIN(j41lURISS: // SANITARY NO. AI'1'LICATION SUIiM.I1TI'Ah DATE
19;&/r/IINITN LOT#
OWNERS NAHONE: )NTRACIORS NAME: LIC NU: VVV
!1 �4aaJz V ,�, WC CONTROL.#
• ARCHITECT/ENGINEER: N LIC NO: WRES : ❑
d2, of t ve e
CONTACT: PHONE PERMIT /yt T• BUILDING PERMIT INFO
Jf QTY. ELECTRIC PERM
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CdRTRACVSDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OKZ Ihcreby affirm that l am licensed anderprovisionsol'Chaptere)(commencing with iaa�
900 Section 1p(foof Division 3 of the Business and Profession Code,and my lianseisir PANELS \W J
fZfF.. full force and elft.
w Liccnu Class Lic.N? UP T0200 AMPS
R
y Date. 7 L Comrmlor 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Feel ARCHITECTS DECLARATION OVER IBRO AMPS
0 OL�q I understand my plans hall be urod as public records.
oe
W SIGNS ELECTRICAL
Q F„, Licensed Professional -
4yc4Q OWNER-BUILDER DECLARATION SPECIAL CIRCURIMISC.
WO pLL,LJ 1 hereby affirm that 1.n exempt from the Convector's License Law for the
3a y following reason(Seaimn 7O3l.5,Business and Professions Croda Any city ser county TEMP.METER OR POLE INST.
�LLOj wM1irM1 rtquirtse permit to cmnsWn,elteq improve,demolish.or repair anyaWcture
�ee>-� prunm its issuance,also requires the applicant forsuch pcmuuo file asigned statement POWER DEVICES
a 0 IM1e he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter aVALUATION�xo�' 1)(communeing with Section 31N10)of Division 3ofthe Businessaad Professions Cade) SWIMMING POOL ELECTRIC
W_m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of � ' O�O
FZa Section 0031.5 by anyapplicaut for a permit subjects the applicant to a civil panelty of OUTLETS-SWRCHES-FIXTURES
not mom than rive hundred dollars($500).
S q .
N�m El 1,asownendtheproperty.ormyemployee.with wagerer lhcirsolecompensation, NEW RESIDENTIAL ELECTR -SQ.FF. SIORIES TYPF;CONSTRUCI'ION
i will do the work,and dwaruc.re isnot intenderim.ffered for.ale(See.'h)44.Business
and profession Cade:The Contncmr's Lienar Law does not apply.an owner of
property whobuildsorlmproveathcreon.end whodoea such work himselfan somghhis
employees,provided that such improvement.anot intended oroffered forsale.if, OCC.GROUP RES.UNITS
h wmrc
ever.the buildingor improvement is sold within one yearof.ampletimn.the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sala')'
ElI,asowner of the pmpeny,amexdusively mnhading with licensed contractors QTY.to PLUMBING PERMIT FEE FLOOD ZONE APN
msauct the project(Sea 70,14,Bminess and Professions Codc)The Convenor's I rs
License Lawdat not apply.an owacrofpsope-ty whobuddsorimproves thereon,and PERMI'1'ISSUA EI n� / ,
whocomards forsuchprojectswithacont toils)Iicer puna ito Ne Con"cim'sas
License Law. ALTER-DRAT VENT-WATER IIA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW P NLCT.DI,VICE TSD: EF.S
ANIMARY YN
Owner Data DRAINS-FLOOR. F .CO RIiCEIPF#
WORKMAN COMPENSATION DECLARATION SCH LTA% YN
21_1�hxrchy affirm that l have a certificate of consent w self-insure,or a certificate of FIXTUR ER TRAP RECEIPT#
Workeri Compensation Insurance or a ccrufed copy therref(Sec.3800,Lab C.)which mW PEE Y N
coven all cmpluyee's under his Permit. GAS-EA.SYSTEM-I INC.4 OUTLETS Rli':IPI p
Policy# Bl LDING ISION nu
ContQQyy��y GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK eE
Q�Cenifed copy is hereby famished.
❑ Cenilied copy is filed with the city inspection division. GREASEANDUSTRL WAS'TF.INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIL
COMPENSATION INSURANCE
(Thisaectammadnot be completed Kiln,permit is fuone hundred doll..($100) SEWER-SANITARY-STORM EA.2001"1'. ER'Y FEE
or less.)
I certify that in the perfomance oflhr work for which this permit is issued.)shall WATER HEATER W/VFNT/ELECTR
mol employ any perstm in any manner son m bee ay Jen to the Wohen' PAID
Campensotion�{ fC��I1n#nye. . e l WATER SYSTBM/1'REATING Uar eciplp
O Z Applicant Vie(/— G
Z � NOTICETO APPLICANT:If,afmrmaking t sC ificateof Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
F .�.
become subject Worker's Compensation provisionof Ne Labor Coda you must ,
forthwith comply with such Provisions or this perniuhe]be deemed revoked. BUILDIN 'E _ra
,
D.1 L M .
Q CO NSTRUCHONLENDING AGENCY SEISMI
p .�v
Uz Ihereby hich t that is asued(See3l97,Civagency for the performance of TOTAL: ELP RIC iE
C) O the workfar which this pemtil is issued(Sec.3097,Civ.CJ
lender's Nume UM NG FfAi
D" F Lender.Address QTY. MECHANICAL PERMIT FEF,
0 U 1 certify that I have read this application and atate N.the above information is
>" Lia correct.l agree to comply with all city and county ordinances and cute laws relating to PERMIT ISSUANCE MECHANICAL FEE
F-' Cg) building emontation,and hereby amhonaa representatives ofthis city to enter upon the CONSI'RUCIIONTA%
ail U Z sMwe-mcotioned property for inpediun purpaa d. ALTER OR ADD I'O MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
I iabilitics,judgments,costs and expenses which may in any way summit against said City AIR HANDLING UNIT(TO 10,000 CFM)
in err''15 A9r¢n.coflhegmafnRof thn it.
AIR HANDLING UNIT(OVER 10,000 CPM)
1�6z 7//
Stgn.m
uo pphcanVContan Dere
m EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1(10.0(10 BTU) Dale eceiptp 1
Will the applicant or future building occupant stare or herdle hasardoua material HEATING UNIT(OVER 100.1100 BTU) TOTAL' bd. �0
as defined by the Cuperin,Municipal Cede Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'! VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUAN/E DJUE
Will the applicant orfuturebdiding«cupant umequlparent ordevices which emit BOILER-COMP OHP OR 100.000 BI'U) {k
hansoms air common..nta aay s defined by the BArea Air Quality Mandarins., BOILER-COMP(OVER 100.00f�,q�
0 BTU) IT A 113
Di.arictl
❑Yes ❑No NEW RESIDENTIAL M13C11. SQ.I'I'.
I have mud the hamrdous materials requireey��ments under Chapter 6.95 of the "JUL M 1 M3
Calif anda I Iealth&Safety Code.Sections 25505,25533 and 25534. 1 understand the
I I the building does not currently have d tenant.that it is my responsibility to notify the
Ococcupant of the"comments which must he met poor to issuance of a Certificate of X11 Y Ur III
cupancy. ���/ j� ��/�'�\•
Owner or umhoribd agent Date TOTAL: ISSUED BY. /�� '