25533 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .D1NfiEIFf'TRICA, PERMrrNO.
APPLICATION/PERMIT PLUMB N MECHANIC AL n C C 3 q
BUILDING DIVISION BUILDING PROJEC'TIDKN'1']FICA'1'DON
LJJ J
BUILDING AADDDRES�SS(� r' SANITARY NO, APN,ICA1TIONSUBMITI'ALDATE
LIrl:727 � ��/TN --I UNIT# LOT If �ay�
OWNFi S NAMEa �PHOsH:,�Oo CONTRACTOR'S NAME:
LIC /V
NIC CON'I'RULp
1RCNITECT/ENGINEER: LIC NO: a�33o Q.S CEl
CONTACT: PHONE:
/7 QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
,Q/ //� rJ'SJ��M BLDG F1ECr PLUMB MECH
" C� J J V✓ PERMIT ISSUANCE ❑ ❑ ❑
LICENSEDCONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL
M=z Ila,mbyoBlrmthot l um licensed underprnvisinnso Chapar 9(commencing with JOB DESCRIPTION
1x100 Section]0(10)of Division 3 of the Business and Professions Cale,end PANELS
license is in PANE
fy—C . full Least and effect. UPT0200AMPS 113
QZ� License Class Licp
h Q y Date Cmnractor 201-1000 AMPS
ZOrNi,Z ARCHITECTS DECLARATION OVE0.1000 AMPS 'Q.FT.FLOOR AREA S/SQ.FT.
O Z—n I understand my plans shall lo used as public records.
P'l-W SIGNS ELECTRICAL
<YE Licensed Professional
1�yWQOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ax'OaU 1 hereby ofOmt that I am exempt from the Contractors License Law for the � I e `
P1'�+t~i following mason.(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR Ps IN$T. V --s 1� u�I
F a 0< which tnluires a permit to construct,alter,improve,demolish,at repair any structure POWER DEVICES h J n 1 s
f }� prior to its issuance,also requires the applicant for such Permit fileesigned emtemesn
that he is licensed pursuant to the Provisions ofthe Conaucmr's
License Law(Chapter SWIMMING POOL tfi L IG ..vim VALUATION
0. 9(commencing with Scetion]000)of Division 3 ofdre Business end Professions code)
or that he is exempt therefrom and the basis for the alleged exemption.An violation of
{xy^_,� P g pian. Yvi OUTLETS PS-FlxBJ�TsE
F-Z¢ notm mom
Dnfiv any
undredapplicant font Permit subjects the applicant mecivil penalty of
LSO
not more than five hundred dollars($500). NEWRESIDESUNALEIE_- _SQ.PT.
WL:O ❑ 1,asownemf theprbpery,mmyemployeexwithwages as thcirsaleromprncation. STORIES TYPE CONS'rRUCI'ION
width,he work,and the structure is not intended.,bffred for sale(Sec.9094,Business
and P..l'essions Cade:The Contractors License Law does not apply to as owner of
property who build,orimproves dterean,and wtodoessuch workhimself.,dumb hhis
on employees,provided that such improvements aremb intended oroffered!resale.If, OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion,tfieowner- .I.
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lm owner project
(Snspeey,am business
and Profewinna C(kens ae Comdomas
constran the project(Sec.]fano nerofsi and Professions Coda)(fie Contractor's r
Licenslawdoesnotapplymanithacofpmpery who
sed puarimprovu thcrem.end PERMIT ISSUANCE
whoamlmcts nsrsocM1 projects with acammctor(s7liccnscd Oursuenuothe Contractor ALTER-DRAIN&VEWATER EA
License Low. NT- HEA) FEE SUMMARY
❑ I nm exempt urWer Stt. .B&P C for this reawn BACK OW PROTECT.DEVICE OUT SIDE
FL
SANITARY YN
O Date RECEIPT p
DRAINS-FLOOR,ROOF.AREA,GOND.
WORKMAN COMPIcate of ONDECI.ARATION SCIIO01.'I'AX Y N
❑ Ihereby efbrm lMtl Insurance.,
cer fiedo,fficof(Stssute,or erd,certificate.) hick RECEIPI'p
FIXTURES-PER TRAP
Workers'Cmplometionler this ermit. ifiedcnpy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covets all<mployec's under this permitGAS-EA.SYSTEM-1 INC.4 OUTLETS RIiCE1PT p
Policy p BUILDING DIVISION PEES
Company GAS-EA.SYSTEM.OVER4(EA) PLANCHECK FEE
❑ Cer died copy i hereby famished.
❑ Certified copy is filed with the city inspection division. GREASIWNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF,
COMPENSATION INSURANCE
Mix sceionnecd not In completed ifthe permit is Tarbes,hundred dollars(S100) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or less.)
I certify that in the ped ornan¢of the work for which this permit is issued,I shall WAITER I[EATER W/VEN1'/ELECI'R
notemploy any Person in an to become subject lb the Wattle.' PAID
Cumpensmionl WATER SYST1iM/1'REATING Dae Receipt#
Z 0 NOTICE ,afrcr maks rhos Cenlficne of Exemption,you should NEWRESIDENI'IALPLMB. SQ.FT.
TOTAL
.L. baeame subKct to the workers compo tion resistants of the Collor Code,you must
6F's > forthwith comply with such previsions or this Permit shall be deemed revoked. BUILDING FEE
(] cONSTRUCOONLENDING AGENCY SEISMIC FEE
Thereby affirm that there is icon (Sim.3 lending agency for the performance of
U O penal TOTAL: ELECTRIC FEE
Lework Name this tis issued(Sec.309].Civ.CJ
Lender's Name
Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and state that the above information is
�-' L11 correct l agree to comply with all city=it county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL RiIi
building construction,and hereby authorize mpresenwivesofthiscity to enter upon the
U 'z aliose-namioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
r-1 (We)agree to save,indemnify and keep M1umless the City of Cupertino against
liabilities,judgntem;ccnaandexpardesw mayinanywayaceon,ii,ussaid City AIR HANDLING UNIT(TO ULKOCFM)
nconmque thd runtln oft
-3 C19AIR HANDLING UNIT(OVER(0,000 CFM)
A
5-41--1EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERBE L !yr.CLOSURE HEAPING UNIT(PO 1000A)BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,01g)BTU) L:
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 255320)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
p ISSUANCE DATE
Will theapplicarnorlinumbuildingoccupamuseequipmemardevieeswhichemit BOILER-COMP CHIP OR 100,000 BTU)
Nous air emusminoms as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1o0,W0 BPU) PT
i'trin? D
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.Ff.
I have read the harvdous materials requirements under Chapter 6.95 of the SEP 30 19
California Health&Safety Code,Sections 25505,25533 and 25574. 1 undermnd thus
if the handing does not cumently have a tenxlu,that it is my responsibility to notify the ys11 Y
occupant of the requirements which man be met Prior to ixsoaece of a Certificate of V (JI' V l2rChl t t 1
Occupancy, I9 /
Owner or authorized agent Dote 'I OT'AL: ISSUED HY:
0 \