25861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY-9F CUPERTINO �f%-FI:eCrRrCA' PERMIT NO. �k
APPLICATION/PERMIT PLUMBING-MECHASICAL .`5 8,6�I
NUILDINf,DIVISION BUILDING PROJECT IDENTIFICATION J O 1
BUILDING Ay]D 0��1� SANITARY NO. AI'I'LICA'DON SUHMINAL ISA'I
UNIT# LOT# I s_2fs
O 'RS MF.: + . CONTRACTOR'S NAMES/1 LIC NO:
7 CW
l•T^Sif�IIL NIC CONI"ROh N
�ARCIII JEC'f/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: $ e° - - BUILDING PERMIT INFO
QTY w¢ 4 A ELECTRIC PERMIT, ", FEE
:'ERMI Amt NC g.v....Y - B�Dp ELF:C'1'
PERMIT ISSUANCE 'ff7-'�
LICENSED CONTRACT'OR'S DECLARATION OUAPPLIANCES-RESIDENTIAL r TOB DESCRIPTION
Oa'2 Ih7")afirnthaO amlicensed undcrpmviotex,mCheprer and mmencise with 5�y'� 13r
-00 Section
eand)of Divisiun3nfthc Business end R.Posnions Code,and my licemeis in PANELS �I 1M
W<
W IF—. full lune tad effect. /all
FZw Licenx Class Lic.# UP T0200 AMPS' 6�/r
y?y Date Conwctm 201-1000 AMPS SQ.11'.FLOOR AREA $ISQ.FT.
ZOt_Ni— ARCHITECTS DECLARATION OVER 1000 AMPS
M 1 undersmnd my plans shall he used m public records.
OZ W SIGNS ELECTRICAL
a
Licensed Professional
�Iy d'Q OWNER-BUILDER DECLARATION ECTAL CIRCUIT/MISC. p
K1 hereby efimu that I am exempt from the Cnnvacmr's Licenx law for the %3'✓1"`roe{1 � \
W Va1 following remon.(Smile.7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
oe.] which reyuira it permit w conswn,alter,improve,demolish,m repair any structure ! ,(/� '✓
f`r'YS prior In it,scuuncc,also ayuims the applicant fursuch pe.iuo file.signed statement POWER DEVICES
0OzLL that he is licensed pursuant m uthe provisions ofthe Contractor's LicenseLicenseLaw(Chapter SWIMMING POOL ELECTRIC VALUATION
�Xo9(comitment,with Section 7")of Division 3 of Ne Business and Professions Code)Code)
=rn or that he is exempt therefrom and due basis for thealleged exemption,Any violation of O OUTLETS-SWITCHES-FIXTURES �/�
Zee Seen..7031.56y.ny applicant for.pearodmibjects theapplicant roe<ivilpmalry.f 20 66v
K
mthan rive hundred dollars(S5k)). NEW RESIDENTIAL ELECTR —SQ.F1'.
� m I,as owner ofthe propcny,ormy employees with wages as theirsule compensation, STORIES '1'YI'Ii CONS'1'RUC'1'ION
will rM1e work,and the strvnure is not imm�dedoroffcredforsalc(SUA044,Business
and Professions Code:*Me Convectors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through hie
cmploym,,providel that such improvements ar<not intended oroffemlfarsale.IT, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneycarof completion,theowner- T
builder will have the burden of proving thm he did not build or improve for purpose of )
ia1e.). QTY. PLUMBING PERMIT ..FES 11.0 ONE "N(j1,mownerofthepmpeay,ameaclusivelyconvactingwithlicemsedcontncmrsro p I!21 ,n_ n l�
consumer the project(Sec.78,14,Business and Professions Code:)The Contractors
License Law daesnm apply manowncrafpropmim
y who builds or Pmvesl1wmn ,.mI PERMIT ISSUANCE
whocuntmce,formob projects with acentractons)licensed pumuaaamhe Contractor's _
License law. ALTER-DRAIN&VENT-WATEIt(G) Jj h— I •E Y
❑ I em exempt under Sec. .B&P C for this reawn - BACK FLOW PROTECT.DEVICE
DA SANITA Y N
Owner Dam DRAINS-FLOOR,ROOF.AREA,COND. �— I #
WORKMAN COMPENSATION DECLARATION - SCII001,TAX—
�. El hereby affirm that l have asrtificamofconx.t to self-insum,or a arriftcate of F1V'URFS-PER TRAP 'RCC.IPIIp
Workers Compensation lnsummamacedifiedoe'ammmf(Sec.3800.Iab CJ which PARK FEE Y N
Owma.11 employee's under this permit. GAS-EA.SYSTE1,T-1 INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION Fit
Cmnp.ny GAS-EA.SYSTEM-OVER 4(IA) PLANCHECK FEB
❑ Certified copy is hereby famished. _
❑ Certified copy is fled with the city inspection division. GREASEANDUSTRLWASTEINTERCEPfOR GRADING 193E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBTRAP SOILS FEE
COMPENSATION INSURANCE
I his section need not be completed ifthe permit is Turner,hundred dollars($100) SEWER-SANITARY-STORM PA.2WI7, ENERGY FEE
orless.)
T certify that in the surformaa<e of the work for which This put is issued,l shall WATER HEATER WIVFNTIELECTR
not employ any person in any manner so so to become subject to Ne Workers PAID
Compcnsationlawsof C.Ilfomia. Dam WATER SYSIEMITREATING Dam Receipt#
O z Appheant
z 0 NOTICE TO APPLICANT:If,em,making this CeNfcam of Exemption,you should NEW RES]DENTIAL PLMB. SQ,M. TOTAL:
F" f/J became mbjmtto me Workers Competlmden provisions ofthe Labor Code,you must
forthwith comply with such Provisions or Permit shell Ur,decncd revoked. BUILDING PEE R
a A SEISMIC FEE
CON=is a c 10th LENDING AGENCY
Irk for afflornwhich
is there is i constructionlending agency for the performance of
z' Ne work for which this Permit is imuQd(Sm.3097,Civ.CJ ELECTRIC PLL•
L) 0 Lenders Name "
0 F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I certify that I have read this application and Stam that the above information is MECHANICAL FF.E
comer, l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
I--' building construction,and hereby aurnumee repmsentativess oft] city mercer upon the CONS]RUCTIONTAX
Vz above-memiooed property for inspection purpous. ALTER OR ADD TO MECH.
(We)agree roe save,indemnify and kap harmless the City of Cupertino against
llabilitiecjudgments,cors and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO 10,000 CFM)
x Lena of the granting of his permit.
AIR HANDLING UNIT(OVER 10.00i CFM)
Sigram of ApplicangCmdraaor - Dam EXHAUST HOOD(W/DUC) PAID
HAJARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I0g00)BTU) Date Receipt p
Will the applicant or l mum building occupant store or handle hrzomm material HEATING UNIT(OVER 100.(kp Hl'U) T 'Ah
m def ted by the Cupertino Municipal Coda Chapmr 9.13,and the I leallh and Safety
Cale.Section 25532(a)'1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSLIANCEIDATE
Will thea licanrorfmure building occupant tordevices whichemii BOILER-COMP(31 IF OR 100.(00 BTU) 1��
pp gn pun yuipmw T Y
ha amour air contain an m defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,"BTU) I D
dctP J�
�"am
❑Yes ❑No NEWRESIDENTIAL MECH. SQ.IT: Af'9 'J
1 have read rhe hazardous materials requirements under Chapter 6.95 of the /� � /
C.alifianisl veth&S.my Code.See 25505,25533 and 25534. 1 understand that C�ry9g4
if the building does am curzcndy have.maant that it is my responsibility m mail',mVe h CUr
mcupam of the re,manoms which tour be met prim m immince of a CeriGcate of
owner nr aulnomed ,at Dam / ISSUED BY: v ate" '%
OFFICE