25615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BInLbING-RLccrR[C PERMIT"°.
APPLICATION/PERMIT - rL.umxlNr,-MECHANICAL, C L` 9 �,
BUILDING DIVISION BUILDING PROJECT IIIRN'llk'ICA'IION J v 1 ea
BUILDING ADDRESS: SANITARY NO. APPUCATIONSUBM[TTALD,VB
Z pi UNIT# LOT# ley-- /c 3
OWNERSNA E: PHONE: CONTRACT NAA LIC NO: L
NIC CONTROL#
RCIII'IECI'/ENGIN/GER: LIC NO: ADDRESS:
Ar" s 7371
CON'fACf: PNONg S4` '+y'Y'•P"�"-'lad%n I•�'J'e- X .•-•BUILDING PERMIT INFO
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tY, ELECTRICP YIT. ,F'GE.
r ^� DC ELE PLUMB M' li
c r Q C PERMIT ISSUANCE IT UL) rw
LICENSED CONTRACTOR'S DECLARATION APPLIANCES- I IAL
nZ. n Ihefebyafr mdrat l am licensed under provisions#f0aper9(commencing with JOB DESCRIPTION
.10W0 Section 7001 Division 3 of the Business and Professions Code,and my license is in PA •IS
yU E full force and effect. �/. e
QyW License cross Liap T u 2 s
Qoo Data Contracmr 0 UXX)AMPS
F,z ABU"',
DECLARATION SQ.FT.FLOOR EA 8/gp.R.
Z Oy�- I understand my plans shall Nc used m Public teeords. ER 1000 P
F y C w SIGNS E
8"D �b sr2,3F
Q� Licensed Professional
x:,9< OWNER-HUB,DER DECLARATION SPECIA CULT SC.
xC W, 1 hereby affirm that I am exempt floor the Condolences License Law for the
W 3 t y fol lowing reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.4ETER OR PDLE INST.
F tj'
01 which egalres a permit to construct der,improve,demolish,or repair any,.......
CEar$ prion,in,s...us..1mosquims duall,icantf«such permitm file.signedstaement POWER DEVICES
W aOO then he is licensed pursuant to the provisions of the Convectors License Law(Chapter
n,'n9(cnntmencing with Section)000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,_, nr then M1c is eaempnherefromand the busixfor the alleged exemption.Any violation of D • O
Y ScOme7031.56 ) pp yo OUTLETS-SWITCHES-FIXTURES 71
FZQ by deed dontrs($50rmit sub'ects the applicant Penalty f 4 f (/
E=p not nyrf ow
wactban or
theprodrty,or myempl NEW RESIDENTIAL ELCCfR SQ.IT. TORIES TYPE CONS IRUCiON
the wrk.an thestreny,armyempinyceswiNwed forads as eirsole compensation,
will dntMwons and the he Contisnor'stertors,Law
not
Business
.it Professions Code:The Contractor's Li«nse taw d«s not apply m an owner of
' propertyw1mbuddso impovesthereon,and whod«s such staklaimulfndumnghhis ,
on employees,provided thatsuch improvements an,not intended cardboardloranle.If, OCC.GROUP HFS.UNITS
however,live building or improvement is sold within one yearefeompichim.the owner- TOTAL:
builder will have the burden of moving that he did not build or improve for purpose of
sole.). QTY. PLUMBING PERM IT '
❑ I,m--owner of the property,amexclmively contruling with tie<ruwconvucmrsm FF;E FLOOD ZONE AI'N
instruct the project(Sec.9Bt4,Business and Professions Code:)The Convacer's
I «
License Low Jsnot m
pplyan nwnerofpropcny whobuildsorimproves thercoPERMIT ISSUANCE n,and •o�
whocnntinG%for such projects with a<ordractops)licenced pursuant to the Contractors
License Law. ALTER-DRAIN ffi VENT-WA'I Flt(HA) FEE SUMMARY
❑ I um exempt under Sea .B&P C for this reason BACK FLOW PROTECT.DEVICE OGI'SIDh PIiC$
SANITARY Y N
Owner Dat° DRAINS-F R R ON RECEx4a
WORKMAN COMPENSATION DECLARATION f t SCHOOLTAX YN
�❑ Ihemb affirm that l have aceniGcate ofemeart toself-insure.oraceniftcaec v L'�✓ u RECEIPfM
Y li FIXTURES�PER TRAP:`
Worken'Cnmlicnsadon Insurance nr aceni0ed copy thereat((S«.]800,Lab CJ whir C= PARK I:Eli Y N
covers all employee's under this permit. I GAS-EA.SYSTEM-It INC.4 OUTI.EQ� RDIVISI N
Policy N BUILDING DIVISION FIiEs
Company -GAS-EA.SYSTE E PLANCHIiCK FEE
ElCcriliet copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. �yg� _ _ O GRADING FEC
CERTIFICATE OF EXEMPTION FROM WORKERS' --GREASETRAP SOILS FEE
+ COMPENSATION INSURANCE
This section need not be completed ifthe permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.2071 ENERGY FEE . pO
or Ices.)
Icenify that in the performance of the work for which this permit is issued,I shall WATER BRAYER W/VCNT/ELECTR JI
not employ any Person in any mwncr su as a bject t e Worken' PAID 10 2:1—
Co-
-�
Commensation Law o Califomuu. Date �•wu'c L � WATER SYSTEM/IREATING Dae Receipt#
Z A licant ala ' ~
Z 0 NOTICE.TO APPLICANT.If,after making this Cenifiema of Esemp`p0m.you should NEW RESIDENTIAL PLMB. SQ.Fr. 'IOI'AL: S�
r become subject to the Workers Comprnsetim previsions ofthe Lather Code,you must
t-' forthwith comply with such provisions or this peman MaH be deemed revoked, BUILDING FEE Q•<��I
Ja ?
6. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE g
Z I hereby affirm Nat dome is a construction lending agency for the performance of
U O the work for which this Nmol is issued(Sec.3097,Civ.CJ A ELECTRIC FIeE s�
Lentlef's Name PLUMBING FEE
D' F Lenders Address QTY., MECHANICAL PERMIT FEE
0 U I
certify that I have read Nis application it see that the above information is - �k MECHANICAL FEE
>"' l2a correct.I agree to comply with all city surd county ordinances and state laws relating to PERMIT ISSUANCE ,V
E-' mildingcorevuchoo,and hereby maboriae representatives of this city to ems upon the CONSTRUC IONTAX
IJ z ulxwe-mentioned property for inspection puryoses. ALTERORADDTOMECH.
(W<)agree to save,indemnify and keep harmless the City of Cupertino against
Ilubiliries.judgmoms.croses mdexpenseswhich may in any way scerueaguinst said City AIR HANDLING UNI'I'(TO 10,000 CFM)
inclose�pgrenceofthcgmntingof this permit. AIR HANDLING UNIT(OVER 10,(10)CFM)
SlaeroMApplmvm/Gs rmutor� � Data EXHAUST'HOOD(w/DUCI') PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('I'0 I00.000 B'TU) Data Receipt#
Will the applicant or future building occupant store or handle broadens material HEATING UNIT(OVER I00,000 BTU) TOTAL^
asdefnedbythe Cupsom Munyion[Cod,,Chapter 9.12,and the Health and Safety
Cele,Scetion 25532(n, / VENTILATION PAN(SINGLE RCSID) _ UD
❑Yes ISSUANCE DATE
Will uppllcaat�rfmumhuilJing«cupant useequipmem cadeviceswhich emit BOILER-COMP(311P OR 11q,BW❑N7
haszrJous air sxmtarmma�Zfined by the Bay Area All Quality Management BOILER-COMP(OVER I00.000 BTU) g�] p 1 O
District? f A
a
12 Yea NEW RESIDENTIAL MECII. SQ.FT.
1 have read the hoondoes materials requirements under Chapter 6.95 of the ^ err q �gg3
Caldron.lboull&Safety Code.Section,25505,25533 and 25534.I understand that pE,
if the building does not currently have v lewin,that itis my responsibility m notify theAlai
«,.pant of the requirements nice must be met poor a is: f a Certificate of fit'Gln I llq
s
Owns mercJ ngcsmLl^n')] (d — TOT 1.: ISSUED BY:
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