25141APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOmm:DrA
APPLICATION/PERMIT
,- ,„
I'LUMIiINC-MECHANICAL
PERMIT NO.
2 5141
BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
BUII,I S. 1 1
SANITARY NO.
AN'LICATION SUBMITTAL DATE
PP F 0 C
UNITN LOTp
OWNERS NAME: PNONEQ,uIV
CONTRgCfOR'S NA�S1f /�l /
N/C
0
COMROLx
DaN 11 IS- xw-lY-(,y.�L (-bt ����
ARCHITECf/ENGINEER: LIC NO: ADD
,qV 1.1
1`J �J � J
CONTACT: PHONE:
PERMIT
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT P1.513 MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S UECLARA'1']ON
CM1apmr9fcommencing
APPLIANCES - RESIDENTIAL
JOBDF_SCRIPI'I N
Ihe,ebyafD, thamlem licenced under provisionsor with„
,r�
Setioreland ofect. on3of Ne Business and Profsessi�ns CMe, wd mylicenseis in
PANELS
1
Vrd
lull force and effect. S.1 j 87 /
License C��las)) [ %-q Llcp h
UPT02MAMM
Dam 1J11Q� ConTS
- 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
D OV
ARCHITECTS DECLARATION OVER 1000 AMPS
I undcrswnd my plans shall be used as public words.
SIGNS ELECTRICAL
Licensed professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hercby affirm that I nm exempt from the Contractor's License law for the
following reawn. (Section 70315. Business and Profession, Code: Any city or county
TEMP. METER OR POLE INST.
which requlms a permit m construct, niter, improve, demolish, or repair any stauemre
,,let it, issuance.k. Corpora, theapplicaatfor suchpemtilm file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
VALIgIl W)ry
9(commeneing with Section 71))Eof Division 3 of the Businewmal Professions Code) SWIMMING POOL ELECTRIC
nhcrcrmmand the for exemption. Aryl olmItymicat of
onhutla, 'u1.5
vasis rmit is he
notion by any applicant for a permit objects the epplicann. a civil penalty of
by
OUTLETS - SWITCHES - FIXTURES
a fb n
not mmcthunroftheprohundred dollars
NEWRESIDENTIALELECR SQ.FI'.
STORIES
I'YPECONSTRUCTION
myem).
❑ opery,ormyempiny«s wlthwegesasalei(Sce. compensation,
work,
and the ed 1814, Business
will do the and
tions isodense
-
ch no Cure
Cade: The Law not apply to an owner of
Prodewons trersor's License Law does o, apply
pandro erty who improves uch
properly who buidmr improves thereon and who d«a ouch work M1imulf oT through his
OCC GROUP
RES. UNITS
w�.r.ffered fmde. aIf.
nempiny«s,providedthet such improvemenmarenot immded
however, the building or improvement is sold within one year of completion, theownea-
TOTAL:
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
ElI, asawncrof the pmpcdy, mneadusivelycanwning with licensed contrazmnto
construct the project (Sec. 7014, Business and Professions Code.) The Contracusrs
License Law does not apply toanowmerofpropeny who builds., improves themonand
PERMIT ISSUANCE
who contractsfnrsuch projects with a contructm(s) licensed punoammthe Contractors
pLTER-URAIN&VENT-'E )
FEE SUMMARY
License Law.
❑ I am exempt under Soo. . B & P C for this reason
BACK FLOW PROTECT. DL
OUTSIUI: PEES
Y N
RECEIVL#
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF, ARE
LTAX Y
❑ I herebyaffirm that l have a certificate ofcommat toselfimurc. or cenificam of
FIXTURES - PER TRA
RF.CEIPI'p
PARK FEE Y N
RECEIPTp
Wmkers'C.mprmmm. loommorm. codified Copy therenflna. 3800. Lab C.) which
oven all <mpin se's under permit
Y
GAS -EA. SYSTEM -I INC. 4 OUTLETS -
BUILDING DIVISION IT3ES
Policy It
Company
GAS - EA. SYSTEM -OVER 4LEA)
PI-ANCHECK EEE
❑ Certified copy is hereby famished.
GRADING FEE
❑ CadlOed copy is filed with the city inspection division. GREASPpNDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
V.9ERGY FEE
('This section need not be completed if Ne permit is Lorene hundred dollars IS 100) SEWER - SANITARY - STORM FA. 2WFT.
or less.)
I eerily that in the performance ofthe work for which tbispermitis hatted,ishall WATER FIIATER W/VENT/ELECIR
not employ any person in y er so t nqe subjem to the Workers'
PAID
D—ata it
WATER nYSTIiM/1'REATING
Data Receipt p
n"trlp`,...'looms soflGul.Temic. [J
ys/L I
AI
NT:1Tlf, after m+ekil!
NUI CH .IC ngQrs4Ceeiricate o Exempti.n. ynusbould
NEW RESIDIIJTIAL PLMB. SQ. Ff.
Tc L:
meomesubjct to the Worker's Compensation pmvisinns m da Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed uvokW.
BUILDING FEE
SEISMIC FEE
CQNSTRUCTION LENDING AGENCY
I hereby affirm thanhere is a cortswction leading agency for they ufnr i,.f
TOTAL:
ELECTRIC FEE
the work for which this permit is issued (S«. 3097. Civ. C.)
Lender's Name
Landers Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I unify Nal I have mad this application and dam that the above information is
M17CIIANICAL FEE
correct. I agree to comply with all city and county mdinancea and state laws relating to
PERMIT ISSUANCE
CONSTRUCTION TAX
buildiagconstruai.n, and hereby authmise representatives of this city reenter upon the
above-mentioned prepcdy for inspection Pur awa s.
ALTER OR ADD TO MECH.
(We) agree to save, indemnify and keep fo rmle.u,rytvhe City of Cupertino against
way rearcagaiaom,mid City
Iluhilitics,judgmentx, roars and cnpcnuswhi<h mall-
AIR I IANDLING UNIT(1'0 10.01(kI CFM)
Imu9ucmc fda gmntingo di pe
� 4`/c
s'a
Gl CT
` ar
AIR HANDLING UNIT (OVER IB,OOd CPM)
Slgnul a Applicant/Commtor Dam
EXIIAUS'I IIOODfWMUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ('0101),000 BTU)
Date Pectin If
T AI:
Will the upplieam or fature building occupum store nr handle hara,dous material HEATING UNIT (OVER IW.000 RTU)
as defined by the Cupertino Municipal Code. Chapter 9.12, and the I health and Safety
Code. Seaton 25532m)?
❑ Yes ❑ No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
BOILER- COMP OHP OR IM,000 BTU)
Will the applicamorfuture buildingmcupant auequipmentordeviceswhichend
hmurdous air contaminants as defined by the Bay Arca Air Quality Management
BOILER - COMP(OVER IW,000 BTU)
p7 gY
Dealer?
I(- N D
❑ Yes ❑ No
NEW RMIDENHAL MECH. SQ. FT.
I have mad the haamdous materials requirements under Chapter 6.95 of the
IIP�]
8
Culifomia Health & Safety Code, Sections 25505, 25533 and 25534understand . 1 undersnd that
MAY 199
it la, in ilding d«s not cummdly have a tenant, that it is my responsibility to notify the
io, which must t prior to Ice of a Cedificam of
occupant of me rewrcrcnmuhe mensmm
OCCU
CtIY Uf GurtHl' u
aney.
ISSUED BY,
Owner or authorized agent Dale TOTAL: