25676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOSDI t.-E. i RICAL FERMI"f NO,
APPLICATION/PERPLUMBING:-MECHANICAL.
MIT /1 /N�g/N
BUILDING DIVISION BUILDING PROJECTIDF.N"I'IF'ICA'1']ON L Y6 / i6�
BUILDING ADDRESS: SANITARY
/��I Ik`1 n SANITARY NO. APPLICATION SUBMITTAL DATE
60 S ycr S v[Il OIY �•', �� UNIT# LOT#
OW_ RS NAME. IV PHONE: �� CONTRACT A G �IC NO
J. ' {� 1_4
V (/ NIC CONIAOL#
RCHIT..... .INEER: I ICNO: ADDRESS/ 3 El
oyI�ic
CONTACT: . . PHONE:
"�. QTY. , ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�{��f NLD GCT PLUM MliCll
W 0 Z y+ /v PERMIT ISSUANCE v •'�
LICENSED CONTRA OR'S DECLAIiAI'ION pppl.lANCES-RE.SIDENTIAI. LOB DISCRIYTION
pp.Z I hereby affirm that l am licenaedeader provisionso(Chapter9(commencing with
1400 SeMon lONq of Division 3 of the Bmimesaand Professions Code.and Any license is in PANELS AAA
<Z, ull.eClaed.
UP TO VIII AMPS
UU top
f r Classdef( Lie.# m
tFitQy Dam Contractor201-Ig10AMPS
ZO",z ARCHITECT'S DECLARATION OV-R READ AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0�Z�O I understand my plans ahall he used as public records.
P4 W SIGNS RLECS'RICA].
$ LiccmW Professional
CW OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O 0I hereby affirm that I am exempt from the Contractor's License Law far the
W 3tv.N following reason.(Section 703 1.5,Business and Professions Code:Any city orcoonty TEMP.METER OR POLEINST.
.F.f9 Jd which requires a pormh to emastmct,aper,Improve,demolish,or repair any structure
Y� prior to its ismanca.1so requites theapplicam forauch permit to fileesignM statement POWER DEVICES
_a pm that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a io y, 9(commencing with Section 7"Iof Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS ��t1\
aSectian103L5hyany Applicant!erapermitsubjects Neapplicanunacivil penalty of FIX �/U./��#
C nm more than five hundred dollars($SW). NEW RESIDENTIAL ELECTS —SQ,FT, fesRI {,,,`,'v
❑ Lasavark. id herpery,ors A.,.1 ra,wiNwagaasale(See 044,Business STORIES TYPE CONSTRUCTION
C will do Newons anile:The rdl
iactotintendede Law
for ntaplc.tan owner
And Professions CMe:The v Contractors dd who Law dos or apply to an owner of
Propenywno yces,pdsorimproveat uch Amer undwhodoes such
tendedroffieer through hisown t
ever thecs,progori prove int is old within
not
eyew rcourpletired forthe ale,wn If.
however avetie barimpmvementiahathe dhinoneyev of compleforpcower T( A e n I�
bPUTuilder will hvvc the harden of proving that he did not build or improve for puryose of L J
11 QTY. - ">PLUMBING PERMIT FEE FLOODf'eON
❑ I,ae owner nfthe properly,amexclusively, conwaing with licensed contractors to eLi g
cottsvua the project(Sec.]044,Business And Professions Code:)The Contractor's PERMIT ISSUANCE TE
License Lawdoes not apply loan ownerofpropeny,who builds or improves thereon,and
whocontrecu forsuch projects with amomwdthd licensed pursuant m the Contmctols PETER-DRAIN&VENT-WATIift(PA)
Licena,Law. F HE SUMN
❑ 1 am exempt under Sec. ,B&P C for Nis damn BACK FLOW PROTECT.DEVICE oil 9 I .1 1:
SANITARY Y N
Owner Date RECEIPT'#
'fI
DRAINS-FLOOR,ROOF,ARRA,CONG.
WORKMAN COMPFNSAONDECIARATION SCHOOLTAX Y N
❑
Workers
Co pensatAfford thmlhave a urance in a ccateofc revent to copy
donol'Stsurc,m aaIS certificate of FlKTl1RL5-PER TRAP RECEIPT#
Workcrs'Compensetion lnsurancemacenifMcopy thereof(Sa.3g00.Lnb C.)which PARK FEE YN
rs all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS R[CI?IPI'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FGE
❑ Ceriliwl copy is hereby famished.
❑ Cerifiedeopy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING TEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisacoma need not armia,leed ifthe permit is forte hundred dollars($100) SEWER-SANITARY-STORM PA.20047. ENERGY FEE
A,Ria.)
I maid that in the Performance of the work for which this permit is issued,I shall WATER HEATER W/VF.NTpiLECfR
not employ any person in any madder so As to become subject in the WorkersPAID
Z Compensation Lawsof Califundo. Date WATER SYSTENUTREATING Date ce t
Applicant
C) � NOTICE 90 APPLICANT:If. fit,AlithisCerifcnteofExemption,ydoshould N17WRESIDEN"GALPLMB SQ.PT OTAL:
L V]
become subject to the Worker's Compensation provisions of the Labor Cede,you must
tY 7 forthwith comply with such provisions or this permit shall he domed revoked. BUILDING FEE �A
d [� CONSTRUCTION LENDING AGENCY SEISMIC EF.
Vz Ihereby affirm thatthem is a construction lending agency for the perfmmaneeof
O the Walk for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC ,E
Lender's Name
I.T.
F Lender's Address QTY. MECHANICALPERMIT' PEE PLUM P.
U I madly that 1 have read this application and stem that the above information is
correct.l agree to comply with all city and county mahmances and state laws miming to t PERMITISSUANCE MEC AANICA FEF
C,,) building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION X
U Z above-mentioned property for inspection puryous. ALTER OR ADD'1'0 MUCI I.
(We)agree m save,indemnify and keep tortillas,the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way amore against said City AIR HANDLING ON]'[(TO 10.001)CFM)
In consrime thegramin of is permit.
M AIR HANDLING UNIT(OVER IO,fKK)CFM)
S' azure of App¢aMCommctor Du 0"11,61EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date eaipl#
Will the applicant or Rome building occupant store or handle hazardous material HEATING UNIT(OVER I W,(q0 OTU) T'O'TAL;
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety —
Code,Secbon 25532(a)f VENTILATION FAN(SINGLE RPSID)
11 Yes ❑No
BOILER-COMP(3HP OR 100,"BTU) ISSUANCED E
Will Wplicamorfmure buildingoccupant useequipmentmdeeieeswhich emit OCT27 1993
♦aurdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IMI000 BTU) (/ JJ
District? `
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. CI I Y fart I✓UTu"GYI I DVU
1 have read the hazardous materials requirements under Chapter 6.95 of the
California I team'&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of u Ceni Pica¢of
Occupancy.
Vo
Owner or amounted Aged Dae TO ISSUEDR .
OFFICE