25694APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO " i.3Y�EI.F.C1'NI AI.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PFRMITNO.
25694
BUILDING ADDR17SS:
SANITARY NO.
APPI.ICAI(ON SUSUUBBMITTTAAALL DATT
12- 7 D r:. UNC r G UNITE 13 LOT
VVV y/
OW IBES NAME!PI IONS:
ON f3Vl;fNd 9 347•°19D1130/3
CONTRACT'OR'S NAME: LIC NO:
.*R— MA—Go S5
N�
11ONTACT:
CONTR'OLM
RCHOTCT/F.NGINEER: LICNO:
ADD HS��� M �`L DO�
PHONE:
QTY. ELECI'RIC PERMIT IEE
OU PERMIT INFO
BL ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihembyaffimi hat l an licensed underprov s of Chapler9(commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
UP T020(IAMPS
Section
rce lin) field side f the Baines, and Ror Code, enJ my license is in
full force and effort. W
LiceneeClxvs i- Lic.p �
,.. I, AM�,/ ��
(�-
Date Cantructar
CHITECTS D IOt
1 understand my plans shall be used ns public record,.
201-1000 AMPS
OVER 1000 AMPS
SSSnnn ...ccc.��rsxx���aaaa
'-111 G.� �✓s tl �i
SIGNS ELECTRICAL.
IIOWNER-BUIIDErom
License) lhufessional
ARATLON
SPCCIAL CIRCUIT/MISC,
U
nm exempt from the Cora License ityw f. the
1 hereby affirm the
Iion
ME
TEMP. METER OR POLE INST.
tthat
ng reason. (Sema ? IS, Business and Co. or county
O
,denProfessions
which he mpmcity
which requires. r, limmcmmodeiaheq improve,demolish,mrepairanyatmeure
prioressissuance,rsurequires thevisiosfor perming summer
POWER DEVICES
the Co Liense La
that he Is licensed pursuant m the provisions of the Contractor's License lyes (,horror
9(commencing with Section ]fl(10)of Division 3aphe Bmineu and Professions Code)
to
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the farm far the alleged exemption. Any violation of
Section]031.5 by any applicant torn permit subjects the applicant a civil penalty of
II 1L -Ort d
L J V
OUTLETS - SWITCHES - FIXI'IIRFS
eta more Than five hundred dollars (SSW).
❑ compensation.
wrk,..d eirorery,ormyemployeeswithwage
NEW RESIDENTIAL ELEC 11 S . FT.
_SQ.FT.
TYPE CONSTRUCTION
do rrmli,(sale
will dmhc work, and is on immnded m tan Business
struchimThe
do
lyes does not apply lf an owner of
e: Com Law act apply to an
and Professions Cale: The Common's Ind
propenywho who
ers,prsarimpmvesthemogandwho amnamdoes ctende oroffeor Nmughhi,
own emplthees,Providedshut Lachimprov arcnot iendedoroffered for sale.If.
OCC.GROUP
RES. UNl9'S
TOTAL:
t e b r improvement is sold within one yens of completion, the owner-
sold wit
however, the have
builder will have the burden of proving that he did not build or improve for purpose of
QTY' PLUMBING PERMIT FEE
sale.).
❑ I, as ownerofthe property, am exchnivelycommeting with licensed cornracmts m
FLOOD LONE
APN
construct the project (Se:. 71144, Business and Professions Code:) The Contractor's
License Lawdoesnaropplytemownere(Wro nywhobuildsmimprovestheman,end
PERMIT ISSUANCE
whocantmes for such projects withacommmor(s) licensed pursuant tothe Cmnmme,
License Low.
ALTER -DRAIN&VENT-WATER (EA)
(
FEE SUMMARY
❑ lam exempt undcrSa. , B & P C fo thia reason
BACK FLOW PROTECT. DEVICE
D_N
SANITARY Y
RECEIVE#
Owner Date
DRAINS- FLOOR, ROOF, AR E. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ 1herebyaffon that l have a celificamofcommin oself-insure, maceni6cam of
Wmkers'Campereation Insurance or a verified copy themof(See. 3800. Lab C.) which
Fl%TURES - PIR TRAP
RECF.IPI'N
PARK FEE Y N_
covers all employee's under this permit
Policy p
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECEIPTp
BUILDING DIVISION FEES
Company
❑ Cenilied copy is hereby famished.
GAS - PA. SYSTEM -OVER 4 (HAL
PLANCHECK FEE
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEL'
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 201
ENERGY FEE
This ucBmisicednot be completed ifthe permit is for one hundred dollars(SIM)
less.)
WATER HEATER W/VENT/ELECTR
I verify that in the performance of the work for which this permit is issued, l shall
not employ my penin in any manner an as to become subject to the Workers'
PAID
Compensation LawsmCalifnmla. Data
WATER SYSTEM/I'REATING
Date Receiptp
Applicant
NOTICE TO APPLICANT: IL after making this Cenificme of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject o the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or permit shall be demand revoked.
BUILDING FEE ra
SEISMIC FEE 1
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a construction lending agency for the performance of
ilia work for which this permit is issued(See3097, Civ. CJ
TOTAL:
ELECTNIC IEEE
1<ndees Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Address
1 verify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and sum laws relating to
PERMIT ISSUANCE.
MECHANICAL FEC
b itidingconsnnie lon, it hereby andtadzercpreunutivesof this city beerupan the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save. indemnify and keep hmnless the City of Cupertino against
liabilitiesjudgments, costs and expenses which may in any way accme against said City
AIR HANDLING UNIT (TO 10,0110 CFM)
unlace ofthe ranting of this porark, /O^� r
AIR HANDLING UNIT(OVER Id.WO 1I7M)
Signatureof ApplicanVContmctor Dam
EXHAUST HOOD(W/DUCD
PAID
HEATING UNIT (TO IMME) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipte
Will the applicant or future building occupant or= at handle henrdous material
ev defined by the CLperino Municipal Cale, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IOO,gIB BTU)
OTAL:
Cale, Selina 25532(a)'I
❑ Yes ❑ No
VENTILATION PAN (SINGLE RfSID)
BOILER - COMP DHP OR IM,0p(1 BN)
ISSUANCE DATE
P IR R Tf11
building equip whichemit
Will tai(
hmmdnm air contaminants as deRnel by the Bay Arra Air Quality Mmagemem
contaam minant his by the ay Ail Quality
Disrio]
BOILER - COMP(OVER 100,000 BTU)
/'41 11 LLY
❑ Yes ❑ No r
9 1993W
OCTFb!
NF.W RESIDENTIAL MECH. SQ. FT.
I have read the hamrdom at
merials requirements under Chapter 6.95 of the
California I health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ifthe building does not tly have o tenant, that it is my responsibility to notify the
tee
JU
Ci /
V lir (;L/"t'ril BV1(+
rmcypentc a requi which must be met prior to issuance of a Ceni1- of
��aa�r'tJ�.�r ! � — 2�Y—
ISSUED BY:
o
Owner or authorized agent Use
ole
TOTAL:
OFFICE