25273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I1OIL7fING-RI1hT-TIETCA. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICnL 25273
BUILDING DIVISION BUILDING PROJEM IDENTIFICATION
BDILDINGADDRISS Jf,.(� /ply./'-�^y--/• / ,l �P „` � 1O � cyso/ef SANITARY NO, APPLICATION SUBMITTAL DATE
��0 S-r4U si V/I'/ x+ Z-// . UNIJITT^'M,�"1'F�/� LOFT#
OWNER.SS NAME PHONE: C ACT'OR'S NAME. LIC NO: J
NIC CONTROL#
CHITIM/ENGINF': -, - es_ _ LIC NO: A ❑
CONTACT': PHONE: ;Ly' 2k*T ° ++RMI BUILDING PERMIT INFO
^ _1 qq QTY y� ;�,rib FdrRIC PERMIT' `FEE
S BL LE PLUMB f
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATTON APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Qzz I hereby affirm that l um licensed underprovisiousofChapter9(commending with
NCO Section 700IOlof Division 3 ofthe Business and Professions Cede,and my license is in PANELS
PK�FF.. full force and effect. /k -_
HZW License Class Id
full
UPTO200AMPS gal^Y�
rn<y hale Gommelin 201-IOW AMPS
ZOZen 4 ARCHITECTS DECLARATION OVER I"AMPS SQ,F1'.FLOOR AR' E/SQ.IT.
O Z'-O 1 understand my plans shall be used as public records.
naTr-
�ynl SIGNS ELECTRICAL
4 Licensed Professional ,3
U OWNER-BUILDER DECLARATION SPECIAL CIRCUILMISC p 0
�OtyF 1 hereby affirm the I um caemPl from the Connector's License Law for the L
W 3 a re following rcdua(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR POLE NST. 17
�i Oma which canines a permkininusWa,itheq improve,demolish,or repair any stecere
CWQ� m its issuance,also the applicant for such D.file air dstadement POWER DEVICES
Tr
prior 4 PP Pani gne 1
Gl p that he is licensed pursuant to the provisions of the Cmaramm's License Law(Chapter
9(commencing with Section 70(g)of Division 3 offie Business and Professioas Cade) SWIMMING POOL ELECTRIC _ VALUATION
y)_y or than he is exempnherefmm and the basis far the alleged exemption.My violtuat of ITUTLETS-SWITCHES- / {1
PI stata -2
a�G Section 7031.5 by any applicant fit,a permit mOtels lhenpplimnt mu<ivil penally of FIXTURES (—UInn '
z not mom than five hundred dollars(5500). NEW RESIDENTIAL ELECfR _SQ.Pr.
W m ❑ I,asownerafihepmperty,ormyemployeeswilhwagesuslheirsolecompensation, STORIES TYPECONSTRUCDON
D, willdo lhework,and thestrucwm isnol intendedoroffaed for aaleyed.71/44,Business
and Professions Coude:The Connector's License Law does not apply to an owner of
property whuboild,mbirproves thereon,andwhodnessuch wnrkhimselfmthrmilb his OCC.GROUP RES.UNITSwnemployees,pmvidedlhatsuchimpmvememsamnotimmndMoroffemd forsale.IL
howeveq ti. r
tlm bulldingor improvement is sold within one yeerofcomplen,the owner.
,T 7�
builder will have the horde.of proving Thal he did not build or improve for purpose m'
sale.),
[II.mowneroflhepmperty,amexclusivelyconvaclingwithlicens conbacmrsto QTY' 'PLUMBING PERMIT ;PEE. FLOOD ZONE APN
instruct the project(Sec.7044.Business and Professions Cale:)The ContNCmr's PERMIT ISSUANCE
License Law does not apply m an ownermproperty who builds orimproves lhereon,end
whocontems for such projects with acontracmr(s)licensed pursuanmo the Conwcmr's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEESUMMARY
❑ tam exempt under Sed ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY YIDD S N
Owner Date pµpNS-FLOOR,ROOF. COND. RIiCIi11T'k
WORKMAN COMPENSATION DECLARATION . .
SCHOOLTAX YN_
❑ thereby affirm Nal l have a certificate ofcomcm to sal-imure,orn cenlficote of 0.7rFul.m
Workers'Compensalion lnsurarimmit certified copy lheof(Sce.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE Y—N—
...
N
covers all empl.yce's under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETSRECEIPT p
Policyp BUILDING DIVISION FEES
Company
[2 Cenificdcopyisherebyfumimed. GAS-EA.SYSTEM-OVER 4(FSA) Pt.ANCII[CK FEE
❑ Certified copy is riled with the city inspection division. GREASEd NDUSTRLWASTEINTERCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS PEEJR #
w`
COMPENSATION INSURANCE
(This section need not ban completed if Ne permit is forone hundad dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE ..►e
or less.)
I cenifyflam in the performwceofthe work for which this penitis issued,Ishan WATER HEATER W/VENT(ELECR
not employ any person in any mender so as to become subject m the Workers' PAID•
CompensalionlawsofColifomis. Date WATER SYSTIiM/rREATING Dole O NOTICEITO APPLICANT:If,am,making this CenificaamfE.ma t'z rod,you mull NIiW RGSIOENTIAI.PLMB. SQ.14.
F-' Vl become subject y the Workers Compensation mitts
provisions ofthelabor Code,you must
a. 7
forthwith comply with such provisions athio penis shall be deemed Nvoked, BUILDING IIiE
CL. Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
V z I hereby affirm Nm there is s construction lending agency for the Performance of
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: I].ECTRIC FEE
Lender's Name
QF lenders AMlreaa QTY ,a MECHANICAL PERMIT FEE PLUMBING FIiE
U 1 certify Nam 1 have read this application and site that the union information is
correct I agrec on comply with all city end county ordinance and at=laws adding in PERMIT ISSUANCE / MECHANICALFF.H
FF-t building construction,and hereby authodse mineuntatives.f dhiscitymeramrifiathe CONSTRUCTION TAX
U Z alimmonationed property for inspection purposes. ALTER OR ADD1`0 MECH.
�-t (We)agree 1.save,indemnify and keep hanless the City of Cupertino against
liabilifes,judgmems,ensla and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I ROM CFM)
in consequence of the grunting of this penia.
AIR HANDLING UNIT(OVER 10,000 CEM)
Signulure of Applierm Cnnvucmr Dale EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEiATING UNIT(TO 100,000 BTU) iaa, Date Rmeipl It
Will the applicant or filum building occapanl store or handle hmmdous material
as defined by the Cupenino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000ITTD) 'TOTAL:
Code.Semina 25532(a)4
❑Yes ❑No VENTILATION PAN(SINGLE.RISID)
BOILER-COMP(JI IP OR M.000 BTU)
ISSUANCE DATE
Will the applicamor future huildingpam
.ccummemptipmeordevices whichemit
hrea A '
maidous air contaminants as defined by the Bay AAir Quality Management BOILER-COME(OVER 100,000 BTU) D
District?
13 yes 0N NEW,RBSIDENTIAh MF.CfI. SQ.IT.
1 have read the hsommua materials equlemems under Chapter 6.95 of the JUL 131993
Calilbmia I Ieohld&Safely Qrde,Sections 25505,25533 and 25534. 1 understand that
ifthe building does not currently have a ananm,that it is my asponsibilily to notify the Chi / CriI utiw
ecupunl of the osim emema which nest be met prior m is mince of n Cedireule M
Occupancy.
Owner or authorized agent Dom ISSUED BY