25847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO cDtNr.RLsae MlLa, PERMIT NG.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJEC'TIDEN'1'IFICA1']ON 5 O /I
J o 4
BUILDING ADDRESS: SANITARY NO, APPLICATIONSUBMOTALDATE
Loy UNTT# L4
O
NETS NAME L�� PHONEf CONTRAf NAME: �.}� LOTH LnICn'NO:
6 1yl- In.L° �I�s_ 30 ^��� dC�j! �R 9 £2rt^ Af� 734 NIC CON ROI.N
•ABEI II /ENGINEER: LIC NO: A�oR�SS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
S
�O /'� / /�, BLDG ELECT PLUMB MECH Ol !— OIC P S µ,g16e /Oso`✓ PERMIT ISSUANCE El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTIONpyy I Immblefirm that l am licensed underprovisions of Chaper9(cummeneing with
FTC2 Section 7000)of Division 3 of the Business end Professions C and my liave is in PANELS
W'tyzw fall fmceund_f `. / W7 -% �i �^/� _ /�
Licrnrmcmd tbo Liap�r IIP T0200 AMPS (�1'/J\iy.rU 1,
tF<6 Date Conva,��. w♦ ♦ E-s- w 201-UlW AMPS
y FQNZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.R.FLUOR AREA S/SQ.IT.
Cl y., I undersmnd my plans shall be used m public retards.
ry W SIGNS ELECTRICAL 11 /� fI
Q� 177- D 114
WU Licensed lkofessionnl OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC, C\N d!T p
gxRca= u 1 hereby uffinm that 1 am exempt from the Contranors License law for base 00 VV 11 l'_.
t+s 3 WO I¢n following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP,METER OR POLE INST. rSMRIM
(=Fa ra.] which requires a permit to construct,alcor,improve,demolish,or repair any struca
}� prior toils issuance,also the applicant forsuch Permit file a signedstatement FEWER DEVICES
p requves PP fermi
Eft
<C that he is licensed punuamso Ne provisions of the Contncwr's License law(Chapter
a0.a� 9(nnnmencing with Section T00(Bof Division3ofthe Business mJ Professions Code) SWIMMING POOL ELECTRIC IFEE
W:2 l or that he is exempt therefrom and Ne basis for the illegedexemption.Any viole roofOUTLETS-SWITCHES-FIXTDRB$Section 7031.5 by any.,deam for a permit mbjectetheapplicaut to a civil penalty of notmorethenBvehundreddollars(SSW). NEWRP.SIDENTIALELGCfR S .Ff.W . ❑ 1,asowneroftheprnperty,ormyemployceswiNwMesastheirsolecompensation, QTYPECONSTRUCION
willdo Ne work,end the structure isnot intended oroffcred forsee(5«.)0,14.Business
and Pmfnvachas Code:The Comrucwrs Liermm Law does not apply 10 an owner of
property whobuildsor improvesthereon,andwhodres such work himselforthrough hieown employees,providedmat such improvements srenotintendedorofferedforsale.If, RFS.UNITS
however,Ne building ser improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose of
suit.).❑ Lasow«rofthepmprty,umexclusivelycantmaingwithlicrosalcon=wmto QTY, PLUMBINGPERMI'f APN
Lroamer the project(Ser.70,,L Business and Pmfessimn Code:)The Commnors
icense Lowd«snot opplyw mawncrofproperty whobuilds«improves thereon,end PERMIT ISSUANCE
who concocts for such projects with a conrmnonle licensed pursuant to the Comrucmts
License law. ALTER-DRAIN&VENT-WATER EA) FEE SUMMARY
❑ 1 am exempt under Sce. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FREM
SANITARY Y_N
Owner Dete RECEIPT a
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION ofoo DECLARATION SCHOOLTAX Y_N
❑ Iherehyaffrmth Insurance
ce ma oteufc opythement usof(Sesure,o,Lab C.)which
RIiCE1Pfp
Workers Comlx9Yn{sgetioynnl�rtes�u lmyn�eseeoryryacmifid copy Jmermf(S«.7800,Leb CJ which FlXTURES-PER TRAP PARK FI?E Y N
Polcyg cmp/ �aL'C 7S Jto. 9 2� GAS-EA.SYSTEM-IINC.40U'I'I.EI'S BUILDINCD EIPT#FEES
Company 2��rb RssN GAS-EA.SYSTENTOVER 4(EA) PLANCHECK FEE
❑ Cenified copy is hereby famished.
❑ Certified copy is film with the city inspection division. GREASE/1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBTRAP SOILS PER
COMPENSATION INSURANCE
(TNs section minced not be complewA if Ne permit is faros,hundred dollars;(SURE) SEWER-SANITARY-STORM EA,2WFT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER HEATER W/VENTlELECIR
not employ my person in any manner so u to became subject to the Workers' PAID
Compensationl-awsof Califrmia. Date WATER SYSfEMAREATINO DateReceiptN
Applicant
O C> NOTICETO APPLICANT,If,after making this Cerbficee of Hamminion,yau should NEW RESIDENTIAL FINE. SQ,FT.
TOTAL:
F ` becrson hwithc mply it WorkersCsionsrthis prmisiomufthe Labor Code,you most
� , bsMwith comply wird such provisions or this permit shall be deemed revoked. BUILDING THE
LLI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Be there is a conmmctiun lending agmcy for the peff«monca of
O the work for which this permit is issued IS=.3197,Civ.C.) TOTAL: ELECTRIC FEE
lender's Name
O U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have most this application and eau the the above information is
W cmre¢ lagrce wcomPly with ell city unJ county ordinances end suuluws relatingw PERMITISSUANCE MECHANICAL PER
_ I, building construction.and hemby auNanmrepresemetives ofthiscity rornrerupon@e
U Z shvc-ro mimed popery for inspection purposes. ALTERORADDTOMECH. CONSTRUCTIONTAX
(We)agree in save,indemnify and kap harmless the City of Crisman against
linhilitics,judgments,costs and expenses which may in any wayaccmeapornaed City AIR HANDLING UNIT(TO IlLare CFMI
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicam/Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,fM%I BTU) Dam R«eipta
Will the applicant or furore building occupant store or handle harardom material
in defined by the Cupertino Municipal Cede,Chapter 9.12.and the 1health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cole,Section 25532079
Cl Yes 13 No VENTILATION FAN(SINGLE RFSID)
Will bac epplicmmrfuturc building«cupmtuseryuipmem ordeviceswhichemitq
BOILER-COMP DHP OR IM.W BTU) ISSUANCE DATE
/• hamrdous air comnmina is as defined by the Buy Area em
a Air Quality Monagem BOILER-COMP(OVER 1110,0010 BTU) P ig
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 hu read dw hurnrdous materials requirements under Chapter 6.95 of the DEC 1 6 199
Celifami calth&Safety Code ani 505,25V3 ad 25534. 1unde
UT-
if tush ingdocs nmc�me con rot. may to ramify the C//r Vl' yys_`
oce. of the require bi met prior to issuance of a Certifioee of L`Fs;1P
Occu
O -mmthonreJ ent Date TOTAL: ISSUED BY:
OFFICE