25437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO m711,,Dmr.E.,r1I1UCAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25437
BUILDING DIVISION BUIIAING PROJECT IDEN'1'IF'ICAI'10N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
r ONI'1'M LOT
OWNERS N NE: ' PHONE: CON'fR CIOR'SNAM LIC NO:
Ur, ^ N/(7 C NTROL#
•ARCHIT "I'/IiNGINEER: LIC NO: ADDRESS: .� El-PIK6I
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB CH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
C7, I hereby affirm that l um licensed under provisionsol'Chapm9
r (commencing with
TOB DESCRIPTION
ts02I�. fallSection
meand of Division 3 of the Business and Pmfcssion/s Code.and
UmYlicense is in PANELS /
mUC) fullfotceanJcffcctn�'l "Lic.x �n� ItJP I UPTO200AMPS I(I,}ACI
aZm Date �C(IYs��s l.� o'�[J
rEia=N Dale T f C.nunctor 201-1000AMPS SQ,ET.FLOOR AREA Sm.IT.
Fmz ARCHITECTS DECLARATION OVER 1000 AMPS
Z0-_ I undermand my plans shall M used i s public records.
Ozl-
SIGNS ELECTRICAL / F\1 / '\ L E D I �`V,
- ■
Q��o
(Yo ,,,,..II
1'Q Licensed l'nslkssional OWNER.BUILDER DECLARATION BPECW,CIRNIT/MISC.
XOiO 1 hereby affirm that 1 vn exempt from the C.nhazlorx Licemc law for the ll It C
W
p-1,- followingSection 7031.5,Business and Professions Code:An t TEMP.ME ER OR POLE IN ' l (\!LIPI G
reason( y ci y oscounty 1
F O Q which requires a permit to conawm,eller,improve,demolish,or repair any awnurt
�rAjs pdo,to ns issmnce.also requires the applicant for such .it on filen signed ewmmen, POWER DEVICES
Wd 0 that he is I ccnsnl pursuant to the provisions of the Conmamors License Law(Chapter -
o.ao� 9(commencing with Section 7)00)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC JI
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Fza Section 7031.5 by any applicant for.permit subjects the applicard civil penally of OUTLETS-SWITCHES-FIXTURES
nm more than five hundred dollars(5500). NEW RESIDENTIALELECTR _SQ.FT. STORIES TYPF,CONSTRUCTION
CFo ❑ Lthe wrk,anheproperryre is not ed de
cumpefwness
a3= willdothewonk,ande:The structure License Law doesmil not apply
to ons Business
and Prnmaan,trx awe:me a,mmcmFa License Law does not apply m lo owner or
pmpeny who mild,mimprmex themon,and whodmssuch work himself.,through bis, OCC.GROUP RES.UNITS
wn employees,provided that such improvements art not intended or offered for sale.IL
however,the building or improvement is sold within me yearefewinplelion.Be owner- TOTAL:
builder will have the burden ofpmving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
r] onm Las owner ofthe property.um exclusively contracting with licensed ceRaxto
ansnmet the project(Sec.70,14,Business and Professions Cde:)The Cionowa is
License Law docs not apply in m ownuofpropeny whobuilds orimproves thereon,and PERMIT ISSUANCE.
who contracts forauch projects withacommelor(s)licensed pursuanno Be Conoazlors
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ Ism exempt under Sec. .B&P C fm this mason OUTSIDE
BACK FLOW PROTECT.DEVICE FF.F_
SANITARY Y N
Owner Date DRAINS-FLOORROOF,AREA,COND. RECEIPI'M
,
WORKMAN COMPENSATION DUCLARATION SCHOOLTAX Y N
❑ Ihercby affirm tbatl havcaanifwm of consent to sdLinsure,orncMificae of FIXTURES-PER TRAP RECEIPI'p
Wmkers'Compenantion lnsuranm.r a certified copy there.f(Sm.3800,Lah C.)which PARK FEE Y N
rs all employee's under this vamil. GAS-EA.SYS'URM-I INC.4 OUTLETS RDIVISION
Puhct
aBUILDING DIVISION FEESny GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
coired copy is hereby fumisho.
cnllied copy is filed with thecity inspection division. GREASIVINIIUSNH.WASTE INTERCEPTOR GRAVING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section mordant be completed ifthe pckrnit is for one blocked dollars(11001) SEWER-SANITARY-STORM EA,200FT, ENERGY FEE
or less.)
I certify that in the pefPoemanm mf Ne work for which this permit is issued,l shall WATER tIP.ATER W/VEN'/ELECTR
not employ any person in any manner so as to become subject to the WorkerPAID
Compmardinn Lawsof Califomia. Date WATER SYSTEM/IRGTING Data Rmcipr4
0 z Applicant
z 0 NOTICE TO APPLICANT.If.after making this Certificate of Brampton.you should NEW RESIDENTIAL PL UL SQ.IT. TOTAL:
f" Le) amparesubjem to the Workers Compenreton provisions;of the labor Coe,you must BUILDING FEF.
SoMwith comply wit such provisions or this permit shall be decmd revoked.
a QSEISMIC FEF.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a constmeton lending agency for the perfrnmance of
7 z P work ork for which this permit is Rained(Sm.3097,Civ,CJ TOTAL: ELECTRIC ME
IL L`ndda Name PLUMBING FEE
V"' F Landers Address QTY. MECHANICAL PERMIT FEE
0 IUI ca that I have read Chia application and atom that the above information is
correct. lagme to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE I MECHANICAL PER
Q' buildingconarrucrion.aadherchyuuthmizerepresenmtivesofthiscityloentetupnnt e
V1 CONSTRUCTION TAX
U z ebnve-menlagned prolixity int inspection and pm,hism ALTER OR ADD TO MECH.
... (wq agree m save,indemnify and kap harmless the dryer Cupertino againn
Iiabilicolies,juJgmenm,c.xman xpenses which may in any way azemeagvn said City AIR HANDLING UNIT(TO BLOWBLOWCFM)
in nuquc fthegern' of this perm ��//yyyp
Y1419 IST L
AIR HANDLING UNIT(OVER 1(1,0110 CFM)
I".` ,col Appl n1VC.mrmI Date EXHAUST HOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT D O 10,0(10 BTU) Date Receipt a
Will the apdicanwr to,..Writing«cupamor hush.hvmJ.m material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Coe,Chupmk 9.12,and the Health and Safety
Core,Section 11532(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No ISSUANCE D
Will theapplicmtorfummbuildingmeupamusecquipment.fdeviceswhichemit BOILER-COMP(311P OR INJODBBTU)
• hverdous air cotmmimnts m defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Fr.
I have read the hazardous materials requirements under Chapter 695 of the ° A ' D
California Health&Safety Code,Sections 25505,25533 wed 25534.I undersmnd that
if the building docs not mnently have a lemnl,that it is my responsibility to notify the
ocAUG 10
cupant of the requirements which muuance
must m met prior to isv .f a Certificate of 1993
Occupancy. VJx7
61 Owner tar amhnrized.,car Date ISSUED BY: --
OFFI