25746 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO ,- LCT ICAL - PERMITNG.
APPLICATION/PERMIT BUILDING PROJECTADPLUMBING-MECHANICAL _ 25746
BUILDING DIVISION F.NTIEICATION• "-
BUILDINGADDRI3SS; SANITARY NO. APPLICATION SUBMITTAL DATE
Z O 58 S G51I UNIT# LOT# I I .Q rY
O E NAME PHONE: CONTRACT RS NAME: LIC NO: N/C CONTROL#
a eT a ti-CLOD
ARCHITF.CT/EN L[R: LIC NO: ADDRES . ❑
4
CONTACT: \\PHONE: rox;46up ELECTRIC PERMIT' : . ' FEE = BUILDING PERMIT INFO
Tj 1 1 YI b a PERMIT ISSUANCE BLOC E PLU MEC
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
aZ - Iherehy affirm lhatlamlicensW uoderprovlslonsofChepter9(commencing wllh ]OB DRSCRIPTION
00 3eelinn 9000)of Dlvis nn 3 0[Ole Business and Prohsslons Coda end my license Is to PANELS �r1
C full Pores and effect. ' UP TO 200 AMPS �� 1
d Z, License CIus6 Lic.#
oo Date Contractor 201-HIS)AMPS
Fyz ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
z O m—OZ-C 1 understand my plans shall be used as public records. OVER 1000 AMPS n
02-
F y k W licensed SIGNS ELECTRICAL
41 q Prnkssional
y�#4 OWNER-exempt RDECLARATION SPECIAL CIRCUIT/MING.
O C I g real affirm that I am exempt from the Contractors e:Anse Lew for the
nl'3 a y following reason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE.INST.
which regoiaa a permit m umnstmcl,ager,improvo,demolish,or repair d
any armoa
�� uirc the applicant for such pe.iuo fileasignul statement POWER DEVICES,
Idor to its u,,mm ,.mvcreq
na'C O that he is licensed poo
ursntto the provisions of the Contractor's License Law(Chapter -
q SWIMMING POOI.F.LEC'I RIC
W 9thatheis ing exempt tSection refromandthe Division Sof theedsexamptndn.Anyiolams Code) VAIAA`TIONa
yYj-,y Sectioheisexbytia,refmmund lhe,.it,ahjcche legeJexemprion.Anyviolation of UTLETS-SWITCHES-FIXTURES �� wV
Section hundred
dollars
the epPlleannoadvil penally of '
not mom than five hundred dollars($500).
� NEW RESIDENTIAL ELECTR _SQ.FT. T ST RIE` TYPL'C4Y STR CI'ION
so ❑ o the wneroflheestructure y,msamintanded oyeeswi[hwagcsasthe(Sec.compensation, ►III /h R B— p1 p pct`
y willdolhewonsCodhasheContlsnor'sLiceseLawrdoesntapplytoan Bantus CYVIIC'� t' f'� pCC✓11 o tl�
ess
and Professions Code:The Gummier',License Law does not apply[o an owner of _
progeny whobuildsorimprovesihereon,andwhodoee such workhimselfor[hroughhis / C O PY '.ON S
own employees,provided chat such improvements are not intended or offered for sale.If,
however,the builJingnrimprovemem is sold within one year ofcamplaion,theowner- Oq L � �a/
builder will have the burden of pav ng that he d'd not build or improve for purp s o of
sale) r z -
e'ards, l,am exclusive) contracting with licensed contractors m QTY] £ PLUMBING P9Rh1IT'� BEE.
pre.70 and
P gest _ _ = y
Cc
vie the project(Sec.]044,Business end Profaesione Codc)'@e Conlraemr's
Dense l.awdoes nuc apply toun0wnernfpmpeny whohuilJsnrimproves thereon,and PERMIT ISSUANCE /
to contracts forsuch projects with aconhactows)licensed pursuant to the Commodes ALTER-DRAIN&VENT-WATER(EA) +FE&SUMMARY-
1 cense Law.
1 am exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE PEE
SANITARY Y N
Owner Date RF,CF.IPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y
❑ lhereby
onapenaffirm rhmihave
rance ora turn econsent to y thereof
Sec.380.acerlifiea[e of FIXTURES-PER TRAP RECEIPT#
-P'arkere'Computemion Insurance oreoenlfied copy thereof(Sw.3g00.Lab CJ which PARK PP,B Y Z N
covers all employee's under this permit. GAS-EA.SYSTEM-i INC.4 OUTLETS RECEI #
Policy BUILVODIV ION PEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKF
❑ Certified uipy is hereby famished.
❑ Cenifedcopy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS
COMPENSATION INSURANCE
('Otis stru n need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20OF1'. G E �.—.r
unless.)
I eerily that in the performance of the work for which this permit is issued,I shall WATER METER WNENT/ELECTR
not employ any person in any manner sous to become subject to the Workers PAID
Comparr iw Laws of California, Date WATER SYSTEM/CREATINO pant eeip
z Applicant
y� C, NOTICE.TO APPLICANT:If.after making Ibis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r7 I;�) become subject to the Worker's Compensation provisions of the labor Code,you must
� > forthwith comply with such provisions or this permit shall lx deproonevoked. ' BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
U rZ 1 hereby affirm rho there is i sued(Sec.3 lending agency for the performance of
'he work for which this permit is issued(Sea.3099,Civ.CJ AW ELECTRIC FEE �I
t.7♦ Lenders Name -" '" - L- - -.- ° PLUMBING PEE
� F IandersAddress QTY. is Q,MECHANICAL PERMIT:
V Icon[y that I have reit this applicationu and sant that the shove interaction regal one A,
IXrrtal lagrea to comply coal all entry and county ordinances and state laws relating to PERMIT ISSUANCE '— MECHANICAL FEE
builiingcanstr a,and hereby cardiae representatives of fits cirym enmrupon he CONSTRUCTION TAX
O 7 above-mention dp penyforinspectimpro.ses. AUT ER OR ADD TO MECH.
rte- (We)."a to save,indenum an keep he ass the City of Capstrom against
liabilities,judg t,costsend x a s hich ay anyway accrue ago ft a ming f maltairwsaid City AIR HANDLING UNIT(TO 10,000 CFM)
.
sequet
AIR HANDLING UNIT(OVER 10.000 CFM)
ignat pprecal/ComrheBay
3 Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARIALS ISCLOSU HEATING UNIT(TO IOOfOWBTU) Dote Reaelpt#
Williheupplicomm(pcupon stro,m Hall hucardouscromai al HEATING UNIT(OVER 100,000BTU)
ea defined by the Cupertino e Ch ter 9.12,and t Heath and Safety TOTAL:
Coda Section 25532(e)? VENTILATION PAN(SINGLE REBID)
❑Yes ❑
BOILER-COMP(3HP OR IOgWO BTU) ISSUANCE DATE
Will Ne applicantorfum am use equipdanum vices whicbemll ^ D
ardous air contaminantshe Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)Dstnlnff �iAY 11❑Yes ❑ NEW RESIDENTIAL MECH. SQ.FT. 199
I have read the hezanlous materials requirements under Coupon 695 of the �/YV r' y JU�
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand[Mr /I Vl• L(fr
if the building does not currently have summit,that it is my responsihility to notify the [
rocupent of the majohn menw which must be met prior hs issuance of o Certificate of 6
Occupancy.
Owner or aurhoriuJ agent Date Tirol
ISSUED BY:
OFFICE