25601 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOSCA. PERMIT NO.
APPLICATION/PERMIT PLUM NINI:-MECHANICAL 25601
IIUIhUING DIVISION BUILDING PNOdECI'IDEN'TIFICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SSSURMI PIAL DATH
1 000 UJUA Cj Rekyj UNITp JbT# el Iq V ��••� l.�
OW F: 5 AM t� 1_ _ PHONE: CONTRp�R-Sat4AM_ E: 1 LIC NO: NIC CONfR01.M
lm
�RCIIfTFCT NG EE : fA„/1, /�YLIE VI j9pADDRE$L' �/r�A�l��k/1 /1
AZZI
CON'T'ACT: 'p,y,J PHONE QTy.j E IC'PEE(RMIT FEE BUILDING PERMIT INFO
Ly��tJ�a��# BLDG ELECT PLUM MECH
I 66 0W PERMIT ISSU NC / Ig
LICENSED CONTRACTOR'S DECLARATION APPLI C -RESIDENTIAL JOBDES IPII(JN
Day Ihereby toff that lam licensed under provisionsol'Chaptu9(commencing wilt
W,00 Section 7000).f Division 3 of the Bmucas and Professions Code,and my license is in pp
OatIF-.. fullhoceanJcffem. QFh�fj —
Fw'u,Lij License Class LiaM
# 0111 APS
co Q a Date Conowsm hipigAddEs
Fyy ARCHITECTS DECLARATION SQ.FT.FLOOR AREA gISQ.FT.
Z 0 r _ I understand my plans shall be used as public records. VER 1(100 AMPS
CZ-0
Fyl_•ty SIGNS ELECTRIC
od'�; Licensed Nnfesxional
a ys�6 OWNER-BUILDER DECLARA9'ION SPECIA CIR U C.
KOdV I hereby from that 1 mm exempt from the Comma ,a Licenu for e
m 3 a y following reams(Section]031.5,Business coil Professions Code:Any<it n ry TEMP.M .R R POLE INS A
gwhich requires a permit m construct,dmo improve,demolish,or' y-c Lire IV
�;!('Y7 prionoits issuance,Wso rcyuires the eppliwm forhuch permiuo file e3igded s at POWE D
thin he is licensed purs......he provisions of Ne Cmdra is License Law( t
K Q
an,
G0 SWIMM LELE IC
9mnrnmaneingwithseatlntn001orDivian,n3onM1eBaa;nexxanaRofaa mhos DAT
'_oy onhethe isexempt thercfmmand the lwsisfm the allegdeaemption.Any violniono OUTLET'S- WTTC -FlXTURES 1G�1.. IoMa
p.Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of V V Lit/
E]
mo a atan five hundred do[].($51). NEW Rf51D BLECTR SQ.FT.
C � E] I.asownc..dtbepropeny,ormyempinyces with wagcsastheirsolecompenauion, STORIES TYPE,CONSTRUCTION
y3_ will dothe work.and the swaumixnot intended oroffered forsale(Sm.]044,Business
and Professions Cnde:The Contractor's License Law does not apply to an owner of
pmpenywhobuildsorimpmvesthcr n,andwhodussuchworkNmselforthmugbhis OCC.GROUP RIS.UNITS
own employees,provided that such improvements ionom itneadd or offined for sale.IL
however,the buildingor improvement is sold within one yearofcompletion,theowner- ail'
builder will have the burden of proving that he did not build in improve for purpou of
1e')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Lan rolthepmp ny,umeaclusivelycomractingwiNlicens contsacmrsto
concoct the projut(Sec.7041,Business and Professions Code:)The Conusetors pERMI'f ISSUANCE
License Law does not apply m an owner of progeny who builds or improves thereon,and
who contracts for such projecia with a comuctor(s)licensed pursuant to the Contractor's ALTER-DRAIN&vIiNT-WATIiN(PA) FEE SUMMARY
License Low.
❑ I em exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE O SIUI:FEES
SANITARY Y N
Owner DateRECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP.AkEA,COND. SCHOOLTAX Y N
❑ Thereby.fftrmthailhaveucenilicateofconsemmaelf-ilnure,oracertificateof FXTURES-PER TRAP RECEI '#
Workers Cnmpensmionlnsurance oracenificdcopY thertof(Sec.381.Lab C.)wbicM1 PARK FEE Y I N
rs all em In ce'0 under this permit. ECE #
P Y pe GAS INC.INC40U'TLEfS BUILDI GDIV ION FIi?S
Policy X
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHF.CK EEC
❑ Certified copy is Inure, d sM1d.
❑ Certified
eJ copy is fled with the city inspection division. GREASF7INUUSTRI.WASTE INTERCEPTOR GRADING FLE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FTE
COMPENSATION INSURANCE
('Phis section need not be completed ifthe permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY 'EE
Lir leas.)
I cenify that in the performance ofthe work for which this permit is issued,I shall WATER HATER WIVENT/ELECR
F not employ any Person in any manner sou to become subject to the Workers PAID
Cnmpensmnmtuwaof Culifomia. Date WATER SYSTEM/IREATING Date Racipt#
0 z Applicant
z � NOFICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F 0, become subject to the Workers Compensation Provisions of the Labor Code,you must
forthwith comply with such pmvisions or this permit shall he doemed resolved.
B LDING FEE /#
Y 7
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE Y
U Z I hereby affirm that them r N
is a construction lending agency for performance of ELECTRIC PEE
Q the work for which this permit is issued(See.317,Civ.C.)
Lenders Name PLUMBING'EE �•
�" F LcnJcrs Address QTY. MECHANICAL PERMIT' FEE
U I cenify that I have read this application and state that the above information is MIiCI IANICAL PEE
W cori l agree to comply with all city and county ordinances and stets laws minting to PERMRISSUANCE
F' buildingconxtmetian,and hereby authoriurtpruenmtives of thiscity toenmr upon the CONSTRUCIONTAX
V 'Z "hove-mentioned pmpeny for inspection puryoxes. ALTER OR ADD TO MECIL
(We)agrec m save,indemnify and kup bmmlexa Ne City of Cupertino against
Ilabilitics.jndgmcros,costs dna expenses which maymitrywayacemeagairelsaid City AIR HANDLING UNIT(TO 10,000 CPM)
consequence of the gran' of this 1100
AIR HANDLING UNIT(OVER 10. CFM)
in
nign re n .nm ctor rlK4 Dam EXHAUST HOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA'T'ING UNIT(TO 11.10 BTU) Date Receil p
Will the applicant or future building Occupant store or handle hazardous material HEATING UNIT(OVER 11.10 BTU)
us defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)'I VENTILATION PAN(SINGLE RPSID)
❑Yea ❑No
ISSUANCE DATE
Will the applicanmrfuture building mcupaniuseequipmentordeviceswhichemit BOILER-COMP(3HP OR 11.000 BTU)
h,um,h us it comaminane,ns defined by the Bay Arco Air Quality Manua na BOILER-COMP(OVER 10(i BTU) P A 10
UisWn1
❑Yes ❑No NEW RCSIDENTIAI.MECH.—SQ.FT.
I have rwa the fm,yC u.materials requirements under Chapter 6.95 of the Q�'T 2119!
Cnlilo ha IIcaah t Safety Code,matlona 25equire ent and 25534.I ter 6.95 of thin
if the building does not currently have a hums,that h is my responsibility to notify the /s
acupnt of the requirements which must be met prior to issuance of a CeniEcate of CITY VI- LVIltm I IIV�
Occupancy.
Ownar or authors agent Date TOTAL: ISSUED BY:
OFF'