24665APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
tl 1 UI .- LRC'1'RI AL PERMITNO.
CITY OF CUPERTINO PLUMBING- MECHANICAL n A C [s C
BUILDING DIVISION APPLICATION/PERMIT L L4 o U J
BUILDING PROJECT' IDFhTIFICA'111IN
BUILDING ADDRESS: SAN[ "I'ARY NO, APPLICATION SUBMITTAL DA I In
IDW10 ,�r`��► UNIT# LOT# ,
•ARCHITC /CNG[NEE0.� LIC NO:
.7410 Q ��� � 4,V
4
CONTACT: 1Ptl/l.'F.:
(�� iiG
Q'fY. EI,IiCTItIC PERMIT PEE
BUILDING PERMIT IT INF
BLDG ELECT PLUMB
PERMIT ISSUANCE
QW.Z
�i100
Cp(4
Fa-
. yZ
Z — M
,-;
(ww<
,�
'OyU
I3u-rFit
. O.O Q
�'yY�
j6 p
t]�
ar
❑y
Y
LICENSED CONTRACTOR'S DECLARATION
I hertbyaffirm that lam limusialmdr,owislrns Ofarldre9(commencing with
Sectinn]WO)of Division 3nfthe Business and Professions Gde, and my license is in
full fomes and effeeg
cense Clas- Lic, p S'+3 ti R �,
Darn g Comnnor
ARCHITECTS DECLARATION
1 understand my plans shall M1c used as public records.
APPLIANCES - RESIDENTIAL
PANELSall
UPl'O 2W AMPS
JOB DESCRIPTION
301 -IOW AMPS
SQ. FT. FLOOR AREA
-
OVER I'M AMPS
GNS ELECT IC
RC CI I SC.
M R OR LF.INST.
'R DT:VICf
Littnmd Professional
OWNER -BUILDER DECLARATION
1 hereby. (Se that 1 am exempt from the Convectors License Law iu the
following reason. (Semon ]0315, Business and Professions Code: Any city or unty
which ox cores a pe.1.1. construct, cher, improve, demolish, ar repair any sou
mins issuance, alarm thea licwofor each Uofileasi atatement
prior 4uirea pp pemri Bned
that he is licensed pumumtto the provisions of the Commcmrs License Lew (CM1apter
9(commencing
xem with Section 'Io0dthe Division 3ollhe Business and Professions Cod e)
on of
or that 7031. by arercfmmanf the Froze( r the mbperllegedearinum.Any ivilpeaud'm
Sat a ]031.5 applicant for o pcnnit subjects the epplicem ro n civil permhy rf
SWIMMING L E IC
VALUATION
yrs
r74/ e/—/1
w V
OUTLFfS - S I' TIES- RES
Gnm
more than five hundred drllare ($SW).
r ha
yempendeswiNwagesasale(Selec0mprnumion.
❑ Lthewrk,anheestruture
NP.W RESID TAI IiCTR _SQ. FT.
STORMS
"IYPCC
d
will Professions and the Ex o sale (tan ner
ow44,
w doesed
t of
License Law dna not apply lf an owner of
he Commem's Lice se
and The Crnrmc
erry whions lds m on,
progeny whobuilds orimprovevM1ereon,end wh0dcessuch warkhimulfomhroughhf,
Jopictio, for
verb
OCC. GROUT'
R
however. thees,provi or imptsuchimpro ommnsarene
is sold within oneyear or theuwncrL
of
hawevecrhebuildinguden
improve pose of
builder will have the burden of proving rhes he did not build or improve for purpose of
of Fr
QTY. PLUMBING PHRMIT FEE
ROODZONE
mlc.).
❑ I,asownerofthepfopeny.amexdorivelYcommning Mi iic.n c..w 1 aro
conelfuct the pmjeeg her. 7044. Business and Professians Cod J'Ine Cammctnr's
License Lawdoanm applymsnownefofpmperty NereOn.and
Pli I'T ISSUANCIi
AITh,�DRAIN&V -WA'1 1'
FEESUMMARY
Braved pumlmproves
whoembacis for such projects with aconmmtm(s)lic<naed pursmmunthe Contmcux's
Licenm Law.
❑ 1 am cacmpt under See. , B & P C for this reason
BACK FLOW PROTF. . DEVICy—Afi
O DI. FE S
ARY Y N
Owner Date
DRAINS -BOOR, ROOF,A ,C
RECEIPT#
WORKMAN COMPENSATION DECLARATION
1❑ (hereby affirm rhatl have nccnNcam ofcomem rr sdf-insure, nracenificam of
Workers' Compensation lnsuranamacenided copy thcreaf(Sec. 3800, Lab C. which
covers nil employee's under this permit.
Policy p
H LTAX Y N
RECEIPT#
KFEE RECEIPT# N
FIXTURES - P TRAP DATE
GAS - EA. SYSTEM -1 INCA OUTLETS
BUILDING DIV ION FE F.
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK ME
❑ Ccnified copy is hereby fumishW.
GRRASEJINDUSTRL WASTE INTERCEPTOR
GRADING IF
❑ Certified copy is Ideal with thecity inspection division.
GRCASE'IRAP
SOI
CERTIFICAT1i OF EXF.MPI'ION FROM WORKERS'
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FFL
(This section reednm fes completed ifthe permit is far one hundred do][. ($100)
Q Z
Z Q
orless.)
I cenifyrhut in the perhmmnceofthn work for which this permit is issued. I shall
not employ any person in any manner as, es to become subject to the Workers'
Compensation laws of California. Dam
Applicum
NOTICE TO APPLICANT: 11,ofar, making this Certificate of Hxamption, you should
WATER I IFATFR W/VENDELECTR
PAID
Duce Receipt
WATER SYSTRM/I'RFATTNG
NCW RIES] DRNTIAL PLM. SQ. FT.
TOTAL:
tr+ V]
?
become subject nigh, Worker's Compensation provisions of the Labar Code, you must
forthwith comply wiN sucM1 pmvisinm ar this permit shall be deemed mvokcd.
BUILDING FTi6
SEISMIC FE
a E
CONSTRUCTION LENDING AGIUsCY
U %.
O
[J..
F
{U
U Z
I hertby nffimt that @ere is owed (See n lending eC.ncy for the p,rfrmunce of
the work Inn which this permit is issued (See 3097. Civ. C.)
lenders Name
TOTAL:
�aF i
ELBCI'RIC a�
Y
Q TY. MECHANICAL PHRMIT FEE
PLUM WE
LemlI sAddress
that 1 have rend this application and sgmc that the above information is
I . I agree
cording Iagrumcomply
,and wiNall uth and county and Stamlaws rclatingm
building construction, and hereby authorize representatives mNiscity to wmrupon rhe
above-mentioned progeny for inspection purposes.
(We) agri to save, inderadly and keep harmless tire City of Cupertino against
liahilitics,judgmems,rnsrs nndeapensa which may in any wayncerueagaion. said City
PERMIT'ISSUANCE
ME CAI. FEII (�
ALTER OR ADD TO MECII.
C44STRUCTIONT
AIR HANDLING UNIT (1010,000 CF M)
AIR HANDLING UNIT (OVER 10.00( CFM)
-onseque�\fnce graftNs pcnnit. !r III
//l1 11 I
Signan. STEM clueenUCnnlmcmr - -7 s s - Date In^^n"" """"t^""` PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,(IOOBTU) Dote Recci
Will the applicamor future building occupant stare or handle hazardous material HEATING UNIT(OVER I WAW IIsU)
a defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Section 2.5532(x)7 VUbIULATION PAN (SINGLE BUSED)
❑ Ycs ❑ No IS UANCE I
Will Neu hrom ar future haddin cu rums laralmdeviceswhich emit BOILER-COMP(3HPOR 100.00 TU)
pp gac pen quip
hazardous air contaminants as defined by the Bay Area Air Quality Management gDILF:R - COMP (OVER I00,000 BTU) P A'' D
Dist ct?
1:1 Yea, 13 No NCW RESIDENTIAL. MECH.—SQ. FT.
1 have read the hazardous materials regoamprols under Chaplet 6.95 of the IFEX 10 1993
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does nor cumently have a renant, that it is my responsibility to notify the �
cogen of the reym
airee¢ wme
nhich must he r Friar to manure of o Certificate, of CITY
r'S yh W rCH I Ilii
Occupancy.
Owner or suNOrized agem Dam ISSUED BY
SiXV
OFFICE