25429 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOun,niNC-nbcr icA. PERMIT No.
APPLICATION/PERMIT PLUMBING,.MECHANICAL
BUILDING DIVISION - BUILDING.PROJECT IDBN"TIFIUATTON 5 /I n (]
5 4 2 9
13UILDING ADDRESS: /.�,1�. 1 (�C 1�I I'(s SANITARY NO. APPLICATION SUBMITTAL DATE
Z(65(o 7/LVNvS CkEEK— 61-( 4MTI LOT#
(JW�NFR4TS�N.AMH: 1'11)8: CONI'RACIOR'SNAMIi: LIC NO: NIC CONTROL#
3AvIO gA.� /#3 45' -2302
\RCIJ,TE_C�'GsE.�NGKO:INEER: LIC NADDRESS:
ANTACT: PI NE: q�y'7 BUILDING PERMITINFO
(„/ -t �i *s0 335—(,// QTY, ELECTRIC PERMIT FEE
DLDG ELECT PLUMB MECH
FRMIT ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IO RIPI'ION
OCZ Ib 7")of
ad otofithe B. nderprovisionsof Li Code,
my tiling with �+
tit 00 Semina er b M Division 3 of the Business and Professions Cada and my rricir is in pprypy$
5nfull forcemtdel(ect 0 3
License ClassLir.# UPT020l
yQy Date Caatmct.,
FooARCIII'I'F,CT'S DECLARATION �G 201 I I"AMS SQ.R.FLUOR AREA $/SQ.ff.20,A OVER WO PB ,
O Z—� wdcrswnd my piens shall be used a9 public records,
SIGNS ELECTRICAL
���d�',,J.l Li5rhxt Professional
y Q OWNER-BUILDER I son exempt
from
m the Co DECLARATION SPECIAL CIRCUIT/MISC.
�4 O a V 1 hereby offer fi m I am uempt from the Contractor's Professions Co e:Any Law for the
fullmv413 p-rj which imr cres a Permit in'l03LS, t.alt e, and improve,deli Code:Any city or county TEMP.METER OR POLE INST.
��yZ pd.,M1 its Issuance,Man
inconstruct.to plic improve,demolish,orrepair any mincident p�
��}Z prior,.its issuance,also requirestheeppliamfor such permiuo file reigned summwt POWER DEVICES pll\V■
fCom'C 0 that he Is licensed pursuunt to the provisions of the Convector's License Law(Chapter iP
9(cnmmencing with Section]WO)of Division3,f the Business and Professions Code) SWIMMING POOL ELECTRIC I - f VAL ON
4I_v, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWRCHES-FIX'N0.ES I L
6 Section 7031.5 by any applicant for a Permit subjects the applicunt to a civil penalty of
not marc than five hundred dollars($50%' NEW RESIDENTIAL ELCCTR _S .FT.
C ❑ I,asowneroftheprop[ny,orniyemployxswithwagesastheirsolecompev"tion, S TYI CONSTRUCTION
I<
_ anilide the work,and the swcmrtis nor imendedoraffercdfor in
sad Transistors Code:Tie Contractor's Licenx Law does act apply to an weer or DANE
pmP[rty whohuildsorimproves tM1ercon,and who does such workhimulforthnrugh his OCC.GROUP RES.UNITS
n employees,provided that such improvements arc not intended or offered for sale.If,
however,the building err improvement is sold within one yearof completion,the owner
er will have the battle.,( that he did not build or improve 'TOTAL:
build
proving prove(or purpuu of
ale.).
❑ Lucowner,fthe przrpetiy,umexdusivdy cnnvnetingwitb licensee camrucmrsrn QTY. PLUMBING PERMIT FEC: FLOOD ZONE ppry i
mmsnact the project(Sec.1344,Business and Professions Cade:)The Connector's PERMIT ISSUANCE
License Law does not apply to an ownerof property who builds or improves forma,and
who ctnumcu rnrsu projects with a contractor(s)licensed pursuant tithe Comoncona
License Lew. ALTER-DRAIN&VENT'-WAT'Rk(It) FEE SUMMARY
❑ 1 um ea ger See. ,D&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY TY DI: EFS N
Owner Date RECHIPr#
DRAINS-I1.00k,ROOp,AREA,COND.
WORKMAN COMPENSATION UECLANATION SCHOOLTAX YN
❑ Ini'Caunflitm tianlum an.m.fcam ofcap,thermf(Sesurc,or Lab
of RECEIPT#
frIXTURliS-PER TRAP
Workeri Compensation Insurance orecetiifed copy thereof(Sec.38W,Leb C.)which PARK TEF. Y_N
coven if emIn s under Nis permit RECEIPT#
Q y GAS-FA.SYSTEM-1 INCA OUTLETS
ol'myp /Yp'Jf- BUILDING DIVISION FEES
C
Company GAS-EA.SYSTEM-OVER4 EA) PLANCHECK FEE
El CMified copy is hereby famished.
❑ CcniOed copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(This soclinn need not be completed rthe permit is for one hundred dollars($100) SEWER-SANITARY.STORM EA.200111'. ENERGY FEE
orle".)
I certify that in the performance of Ne wools for which this permit is issued,l shall WATER HEATER W/VENTIELECTH
not employ any Person in any towner so to bac bjec(,.the Workers PAID
O 7-r CAominrotm oIC i D �T_ '�° WATMSYSTEMGIHATING Date Receipt#
i g 0 1
z0 NOTICETOAPPLICANT:If,aftermakingthis Cenifcateof Enemptiom,youshould NEW RESIDENTIAL PLMB. SQ FT. IOTA:
1-" rn become subjw to the Worker's Compenxtio.provisionsofthe Tabor Code,you mum
� ? forthwith comply with such Provisions or this permit shall the deemed revoked. BUILDING FEI.
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEH
Uz Iheuby affirm that them is a construction lending agency for the performance of
O the work for which th�nnit is iswul(Sri.3097,Civ.C.) TOTAL: ELECTRIC FEE
"adc/s Name PLUMBING IgiE
O F IxoA[/s Address QTY. MECHANICAL PERMIT FEB
U 1 certify that I have mad this application and state that the above information is
Fa embed. Iagree,.comply with all city and county mdommen andsme lawsreleing to PERMIT ISSUANCE MF.CIIANICAI.FEE
building conswa'on,end hertby nuth 'u rcprcxnutiva of this city to rnter upon the CONSTRUCTION TAX
Uz abovome coned prapeny for ins cti purposes. ALTER OR ADD TO MECH.•
(W #gree m sane,inde d kcep homeless the City of Caperton against
liabili'. 'u ta.cs x xs which may in any wayacrom .fast said City AIR HANDLING UNIT GO 10,000 and)
[the thr Permit.
/? AIR HANDLING UNIT(OVER 111,000CFM)
nthw
um a Applicr n r Date EXHAUST HOOD(WIDUCI1
PAID
EIAZ US MATERIALS DISCLOSURE HEATING UNIT(TO 10LM BTU) Dam Receipt#
Will he ap,icam orfumm building occupant made or handle hauNom material HEATING UNIT(OVER 100,000 BTU) 'IOTA :
as dclined by the Capetian,Man'cipzl Code.Clapton 9.12,and the I lesith and Safety
Code,Station 25532(.)❑Yes No7 VENTILATION FAN(SINGLE RESID)
Will tbeapPlicant,.a.. ud 'ngtccupwtuuegoipmrntordeviceswhich[mit
DOILER-COMP 011P OR 100,00013M) ISSUANCE.DATE
�hazardaus air comaminunts s toed by the Bay Are.Air Quality Management BOILER.COMP(OVER 100,000 BTU)
Uiavin'1
El Yes No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read he laimin c.,mut ads equiremems muter Chapter 6.95 of the _ p
Celifomi IlM1&Safety C S do 5505,25533 and 25534.I understand that #sl
iftheb dv
'gme men a rant,that it is my mspoamibility nm
to ifythe - 4s�A
Oc i^t an t mu l H[met prior to issuance of a Certificate of •^VI /� /!
Owner nr amhnrized agent - Date TOTAL: ISSUED BY:
OFFICEHliryV