25704APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I - . RICAL
CITY OF CUPERTINOB .'
APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING DIVISION BUILDING PROTECI' IDENTIFICATI(IN
PERMH'NO.
25704
BUILDI)- DDRES C I �
V UN paw LOTH 1
SANITARY NO.
APPIICA'PION SUBMI"ITAL DATE
1 �'.,�
L ll
OW ER. AME: I NE:
O
RACTO '5 A i .IC
SIC
CONTROLg
ARCifi'I'E /P'WEER: NO:
ADU & D �.r
7
CONTACT
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE
E ❑ ❑
LICENSED CONTRACTORS DECLARATION
IherelfimtN
hyaal lam IicensW under pmvisi.ns.fCM1npar9(commencingwiN
APPLIANCES - RESIDENTIAL.
JOB DRSCRIVI'ION
PANELS
Section 7(IW)of Division 3 ofthe Business and Professions Call my license is in
full fume anJeffect
1
Loc qkoZA_,`/ Lic.#
UPT02W AMPS
w . � -
_
Ua, /i'y-r--')� CnnTS
201 - 1000 AMT'S
— V
D
ARCHITECTS DECLARATION
1 understand tar pinna anml x a.w public records.
OVER 1000 AMPS
SQ. PL FLOONAR1iA
$/SQ. FI'.
SIGNS ELECTRICAL
Licensed l'mfessionul
SPECIAL CIRCUIT/MISC.
(� rD
I horehy of ron that I am.e emLDERpt sm the Contractors License Law On the
J/1 SII
TEMP. METER OR POLE INST.
following reason, (Section 7031.5, Business and Professions node: Any city or county
which patterns u permit to construct, alter, improve, demolish, or repair any struch re
prior to its issuancnalso requires the applicant forsuch permit,. file a signed statement
ATE
POWER DEVICES::61
that he is IicwrsW pursuant to the provisions of the Complainer;License Law (Chapter
9(commencing with Section 7000) ofOivision 3 of the Businessml Professions Cole)
orthin he is axempnhere0vnn nnJ iia basis for the allegedexctmom.Ant Ortatin lot
Section 7031.5 ny any hot for n,crah subjapplicant ects the applicano o civil Paul, of
-
SWIMMING POOL ELECTRIC
1 VALUAJI(gt�ay�
.q �•is„�i✓
OUTLETS - SWI'I'CIILS-PIXTV RIS
t moa than five hundred dollars (SSW).
[II,asnwnerofNepropeny,ormyemployttswothwagesastheirsolecompenmtion,
L
NIiW RESIDENTIAL ELECTR _SQ. FT.
STORIES
TYPECONSTRUCI'ION
willdothework.andthestmcmaisnotimendedorofferedforwle(Sec.7044,Busineas
and professions Cede: The Contractor's License Law does not apply m an owner of
property who nuilasorimprovexthereon, anawhod.essuch work himselforthrough his
wnemployees, provided tha such Improvementsam not intended moffered for sale. If,
OCC.GROUP
RLS. UNIT'S
.TOTAL:
however. the building orimprovement is sold within one year ofcompledion.theowner
builder will have the burden of proving Nat he aid not build or improve for purpose of
QTY: ' PLUMBING PERMIT FEE
-
sale.).
❑ I,asnwnend'thepmpeny.amexclosively comrmting with licensed contractors to
FLOODZONE
APN
instruct the project (Sec. 7004, Business and Professions Code) The Contractor's
LicenseLuwJ..snot apply loan ownerofproperry who builds or improves thereon, and
PERMIT ISSUANCE.
who<ontmcts for such projects with a con,rocmrts) licensed pursuum oldie Cionommr's
Lies. Law.
ALTER - DRAIN & VENT - WATER UDO
FEE SUMMARY
❑ 1 wo exempt under Sec, , B & P C for this reason
BACK PLOW PROTECT. DEVICE
O D S
SANITARY Y N
RECEI'll
Owner Date
DRAWS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARA'110N
SCHOOLTAX Y N_
❑ Thereby vffirm,he,l M1eveocenifco,e of cnnsemloselGinsurc, orecertificvm of
Workers'Compensation lnmommam. cenifell Or, themof(Se. 3800, Lab C.) which
FIXTURES-PERTRAP
RECI;H`P0
PARK FEE Y N
covers all employees under this permit.
Policy N
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FEES
OAS - EA. SYSI FM -OVER 4 (EA)
PI.ANCHECK PLP.
chilled copy is hereby famished.
GRFASE/INDUSTRI. WASTE INTERCEI'YOR
GRADING Mi
Certified copy is Plead with the city inspection division.
CERTIFICKLE, OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
_
SEWER - SANITARY - STORM EA, 200FT.
ENERGY NEE
('Trus neti.n need not Meomplemd if the panni le for one hundreB Jollara (E 100)
a, hos'.)
WATER HEATER WNFNT/ELECTR
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so es to become subject or the Worked
PAID
WATER SYSTEM/1'RFATING
Compeamtion Lowsof Califomie. Data
Date Receipt
Applicant
NOTICE I'O APPLICANT: If. after making this Certifrmoof Exemption, y.ushould
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
became suhject I. the Worker'x Compensation provisions of the labor Code, you must
forthwith comply with such proviso... or this pamd, shall be deemed revoked.
BUILDING FEE
SEISMIC FEE `
CONSTRUCTION LENDING AGENCY
I hereby official that thea is v construction lending agency for the performance of
the work for which this permit is issued (Sea 3097, Civ. C.)
Isnder's Name-
TOTAL:
ELECTRIC PEE
LendersAddress
Q'I'.Y.MECIIANICALPERMIT FEE'
PLUMBING FLR
1 certify that 1 have read this application and state that the above information is
tomo. Iugae, y with all city and county ordinances and state laws relating lo
PERMIT ISSUANCE
MECHANICALMH
building const coon nd hereby authorize representatives of thea city to emerupon the
lent net p pony fnr on purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We ogre to save, Ify and keep bnnnless the City of Cupertino against
;c-
iti ,judgmens,ms odexpenses which may inany way accrue against said City
AIR HANDLING UNIT (TO IO,WO CPM)
of the n' of thispemh.
I
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCD
PAID
rumor Date
'ignam7,.he
,WO BTU)
fAZANDOUS MATS /Its DISC
Data Receipt If
Wrentafumpatsildin pant more m handle hvadois material
asdefinpertino Municipal .Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
'A
Coda S(a)?VENTIATION
❑ No
FAN(SINGLE REBID)
Will phe air co applicant as haiWing by the 01 Arm Air orality on which emit
hazardous air cnnwninenm as defined by the Bay Arta Air Quality Managemcn,
District?
BOILER . COMP (31 LP OR IN,WO BTU)
ISSUANC ; DA
p.I�
Re A i
BOILER - COMP(OVER 100.000 BTU)
Cl Yes 13 No
I have and the hemnlous materials requimmems under Chapter 6.95 of the
!s,
OV - 2 194
NEW RESIDENTIAL. MECH. SQ. FT.
Cnlifomla I [c 1th & Safc,y Calc, S coons 25505, 25533 and 25534. I unde stand ,ha,
ifthe building does not cumntly have atenant, That it is my responsibility to notify the
r
C/�� !
cupan, m me requirements which most be met printl issuance of a Cenifcite of
Occupancy.
Ur
!rt {
qzzz
ISSUED BY:
Owner, m anthorizad agent Dem
TOTAL:
OFFICE