25710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOUTI. IIS—NT.'P.I.MrRI A. PERMITNO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL �]5 7 O
BUILDING DIVISION BUHDINGPROJE(:I'IDEN'1'IPIG'1'IOL
N J /
BUILDING - ;2R ,A )D� �� �k I UNIT# LOT'p SANITARY NO. Al��TION SUBMETAL DATIi
O NERS NNAA/AM�E-H/�/'Y/ P_iv � mss_ �, ^COM2R 'SNAME: _ /C I.IC NO:_� N/C 1 CONTROL
RCHITCQ/ENIGIINNEtii: LIC NO: ✓A,i[/�//1 ADUJBjs iiYTL�� (fLLlf/l'/xHL[1S�+�Qg�r ❑
CONTACT: PHONE. QTY.TY.1 ELECTRIC PERMIT FEE BUILDING PERMIT INFO
' ELEA PLUMB MliCli
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ Ihereby affirm that l am licensed undo pmvieinnsof@apter9(commencingwitM1
�00F. ocolareem Disision 3 afire Businessand Professions Code.and my license k no PANELS -�xJ5///royL� Lo �Q'
<Zw I.ittnu Clay/ Lic.p 933�/�J�.� UP T02W AMPS y-J[� ��#,urf.CG[Sal#
In Q d Date // Contractor =.f_FV_:r / 201-1000 AMPS L• ��K$/S e-[
f,(z ARCI[U1fCTS DECLARATION i/ OVER 1(100 AMPS SQ.FT.BOOR ARG E/SQ.FT.
O°EnO 1 understand my plans shall he used as public records.
F-yF[sl SIGNS RLECfRICAL
Licensed Prsdeesiom.I
hx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaU I hereby affirm that I and exempt from the Conhacmr's License U.for the
W3 m y following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F Eo, which requires a permit to construct.alter,improve,demolish,or repair any structure
C'<2to its iamance,also then applicant for permit file a signedstatement POWER DEVICES
Prior rquircx pp Icmti
tyC<O that he is licened pursuummtbe provision of the Co...,a License law(Chaptcr SWIMMING POOL ELECTRIC
p.ao� 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) VALUATION
,Mot or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWI'1CIILS- / fl
E_'Z Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of FI K'I'USES e (,.`/(/
Ism mom than five hundred dollars T$50).
KFo ❑ I,nownerofthepropeny,ormyemployaswithwageastheirsolecompauadon. NEWT RFI E - -'—\I STORIES gYPECONSTRUCI'ION
y3e—e kand Nru
wdidnthnr , estcmrc is not in¢ndnr
cdnffered ml
far e(Site 7044,Busincas I
cws _• I _
and Professions Code:The Contractor's License law does not apply to an owner of
Pmpcnywho buildsoricapeaves lhereomand whodoes such workhimeelforthroughhis
employees,pmcidedthauuch improvements me not intended oroff<mJ Tarsale.IL11 -' h ' OCC.GROUP RFS.UNITS
however,Lha building(it improvement is sold within one yearofcomplation,the owner.
builder will have the burden of proving that he did not build or improve for propose of
ole.). . PLUMBI •E
❑ I,asnpe
wneroftheprory,amexclusrc
ivelyconttingwithlicenudconimctorsto QTYFLOOU LONE APN
Instruct the project(Sec.70sol.Business and Professions Count The Comracmr',v
I'icerLu law doesnm apply man ownerofpropcny whobuildanrimproves lM1ercan,end PERMIT ISSUANCE
who contracts forxuchprojmawiNacontacmr(s)Iittnud facommtmthe Contncmr's ALTER-DRAIN&VEM'-WATER(EA) FEE SUMMARY
Liccnc Luw.
❑ 1 am cacmpt under Scc. ,e&P C fm this reason BACK ROW PROTEA.DEVICE OU'1:91 UE FEES
SANITARY YN
Owner Dene DRAINS-FLOOR.ROOF,ARG,COND. RItCF:IPI'a
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ eni'Co affirmthatlhrance Orifica¢ofcanumtoulGinsum,or Let,C.) hick FIXTURES-PER TRAP RIiCE1P1'#
Wmkerd Campensationlnthis poracenifiedcopy lhereopSec.3gW,Lab C.)which PARK FEE Y N
n all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUILB RECEIPT#_
Policy N BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(EA) PGNCIIECK EEE
�Ceniredcn ishenebymmida .
Cenilicd copy is filed withthc city inxpcetiandivision. GREASfi/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP SOILS ItiE
COMPENSATION INSURANCE
f1ris,section need not la,completed Blue permit is Lorna hundred dollars($IW) SEWER-SANITARY-STORM G.21X114. ENERGY TEE
or less.)
I cerirytM1a in the Performance,of the work far whichthis permit is issued.)shall WATER HEATER W/VENT/ELECfR
not m
employ any person in any manner so as to hacrle subject to the Worker: PAID
Compensation Lawsof Califumia. Date WATER SYSTR R`REATING Dene Receipt#
Zz Applicant
O NOTICE TO APPLICANT:If,Cher making Nis Cenificateof Exemption,you should NEW RESIDENTIAL ELME. SQ,FT. TOTAL:
F^ become suhjeo to the Worker's Compensation provisions ofthe Labor Code,you must
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FRE
(] CONSTRUCTION LENDING AGENCY SEISMIC FEE
nI hereby affirm dmuhene 1,a wnstucdon lending sicam,far he performance of
.Z TOTAL: ELEARIC FEE
U O the work rat which This pemth is iaaaw(sea.3097,Civ.c)
Lender's Name PLUMBING RiE
O
C F Leader's Address QTY. MECHANICAL PERMIT FEE
U I cenify that 1 have read chis nEmlictlion and nate that the aMve iafnrmaion is M[CIIANICAI.PEE
correct.I agree m comply with all city and county ordinances and slam laws relating to PERMITISSUANCE
F-'
IA building constriction,and hereby authome represenmtives of this city to enter upon IA CONSTRUCTION TAX
U 2 above-mcmiuneJ propenY for inspcnion purpoxs. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep barn as Ne Cary of Cupertino against
liabilitics,j nk,costs end ex n swhic a nany way rueegarmar WCity AIR HANDLING UNIT CTO IQ000 CFM)
in cone curt 'rantil AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicantI onn, Data EXHAUST HOOD(W/DUCI) PAID
IIAZ DOUS MAI'ERIAI S DISCLOSURE
HEATING UNIT(TO IW,IKKI BTU) Da¢ Reccipl#
Will the applicant building occupant score or handle hazardous material HEATING DND'(GVER 100.00)RTU) O L:
as defined by the Cupcnino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'l VF.M'ILATION FAN(SINGLE RESIDE
❑Yes ❑No
ISSUANCE DATE
Will theapplicatorfinure buildingoccupantux equipmntordeviceswhichemit BOILER-COMP(3HP OR 100.00)RTU)
hazardous air contaminants as defined by the Boy Arca Air Quality Manngcmcm BOILER-COMP(OVER 105.000 B'IU)
DisWcf! tl
❑Yea ❑No Ni RLSIDENf1AL MECH. SQ.FT. n'
1 have mad the Insomniac,mar6ma requiremems under Chapter fi95 of the /1x011'/ 3 y^
California Health&Safety Cole,Sections 25505,25533 and 25534. 1 undersand that (� �s / 9
if the building does not stoically have amnant.that it is my rtdminabilily to notify the tl/�/ `�
occupant of the requirements which must be met prior to issuance of u CimiBrate of `r
Owno or authorized agent Data TOTAL: ISSUED 6P M13
OFFICE