25487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
U CITY OF CUPERTINO BUn'LIN7.-MECH NI AI' PERMI'I'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 25487
BUILDING DIVISION BUILD, PIIO.IECT IDEN'FIFILA'1'ION
BUILDING A/DIDRPSS. SANITARY NO. APPLICATION
SUBMITTAL[)AM,
�✓-� //eG1/de" UNE# LOTp d0—Y f3
OWNIA'NAM]ED�� PHONI?:_�� CO GR'S E: LIC NO: N/C CONTROL As
A CHITEJJCJlI'///ENYYGINEER: LIC NOGGONES �^� uy��� - ❑
CONTACT': yyJJ�� ,s, PHONE: �J QTY. DLII?,cCTRIC PERMIT FEE BUILDING PERMIT INFO
/rf.. �i/1-CN �svl zlq —12,2—V PERMIT ISSUANCE El 1:1 El
U ELECT PLUMB MECH
LICENSED CONTRACfOR'SDECIARATION APPLIANCES-RESIDENTIAL J BDP`
0KZ Ihcrcby affioLIC that NSE licensed.CTORvisDECL RATIO (commencingwith
�UOCI Section 7")of Division 3 ofthc Business4d Professions CWe,pad my license is in PANELS
C
full force and effect. ✓U p/ /_I/ IIP T0200 AMPg
FZuti Licen las Lic.
H y Date Contractor 201-1000 AMPS S .FLOOR AR S/SQ.IT.
ZONZ, ARCHITECTS DECLARATION OVER VIIIA AMPS
OZ-0 l understand my plans shall be used as public records.
N
W SIGNS FT FCfRICAL
KQ Licensed l'nfessional
�tYQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
pia,OdF 1 hereby an thot I Am exempt from the Contractor's License law for the
uo'3�m following reason(Section 7031.5,Business And Professions Core:Any city cur county TEMP.METER OR POLE INST.
15 ce which requires a permit to constmet,alte,improve,demolish,or repair any structure POWER DEVICES
C�}7 priono its issuance,also requires the applicant for such permit to file a signed statement
W W 0Oz Nat he is licensed pursuant to the provisions of the Commcmr's License law(Chapter
a eLL 9(commencing with Section 7067 of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA
or ahat lie is exempt hciahnm and the basis for the ulleged exemption.Any violation of OUTLETS t FI R S
G�} Section 7031.5 by any Applicant for A permit subject.the.pplicant to A civil penalty of
T 0 not mom thea five hundred dol W($500).
❑ I,asowneroftheproperty,ormyemployaswith wegesastheirsmlccompmndon, NEW REST 'EL S 'TORIES TYPE CONSTRUCTION
y3� will do the work,And the structure is not imendedproffered a
farsale(Sm.I.,Buaina
and Professions Core:'1'hc Cinalme nr's Liven.Law does not apply to an..net of I `
pmpuny whobuildsor impravesthereon,and whodoessuchwork himselforthmugh his DATE OCG GROUP RES.UNITS
employees,providedtbat such improvemmntsamnot itnendedoroffemd for We.If,
however,the building or improvement is said wMinoneyearofcompledon,the mister.
builder will have the burden of in that he did not build or int for se of TOTAL:
proving prove purpo
s Io.)' QTY. I'LUMBINO PERMIT FEE FLOOD ONE ANN
❑ Lae the proOt(Sec. 044.Bsinesively s ac Professionng shliee sed The Connector's
Livery construct the project(Sec.oano Business And Professions Code:)The Coneon,Ane PERMIT ISSUANCE
Liorelti wdoesnmapply toanownerofpnperry lienbuildse imp roves Con ryand
who Law,forsuch projects with AcomractoKs)littnsed punuanuothe Conlraetoh ALTER-DRAIN&VENT-WATER TEA) FEE SUMMARY
License Law,
❑ 1 wn exempt under Sec. ,B&P C far this reason HACK FLOW PROTECT.DEVICE Tb I:FEES
SANITARY Y N
Owner Dam RECHIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA. SCHOOLTAX YN_
❑ Ihcnhy Affimt Omtlhaveecenificate mf nut.nno.If-insure.on certificate of RECEIPTk
FI%TURES-PER TRAP
Wnrkeri Cnmpensatiort Insurance oracertified cnpythereof(Sec.35W,Lab CJ which PARK FEE YN
coven al I employee's under this permit. GAS-EA.SYSTFiMA INC.4 OUTLETS RECEIPT M
4Policy Y BUILDING DIVISION EELS
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK ME
❑ Cri ified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. a.FlSlll;; S'TRLWASTEINTERCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne Permit is foronehundrW dollars(SIDE) SHWER-SANITARY-STORM EA.200PI', ENERGY FEE.
or leas)
I certifyty eathe performance of,AnAk to
rPeace thwMee,i iisissued,Ishallkers' WATER fIfiATF:R W/VFNT/CLFiCTR
not employ any person in any manner a u to become subject to Ne Workers' PAID
Compensation laws of Celifomia. Dan— WATER SYSTEM/RTI
FFANG Data Receiptp
Z Applicant
zO NOTICHTO APPLICANT:If,otter making this Cenificam of Exemption,you should NEW RESIDENTIAL PLM B. SQ.PT. TOTAL:
fd become subj¢no the Worker's Compensation provisions of Ne labor Code,you must
Fa 7 forthwith comply with such Provisions or this Permit shed he deemed revoked. BUILDING FEE
Lkl CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the permanent.of
O
the work for which this t is issued(Sm.3097,Civ.C.) TOTAL: ELECfRIC FEE pmt
Qlmalaes Name PLUMBING FEE U Lenders Address QTY. MLCIIANICAI.PERMIT FEE
1 certify that 1 have read this Application and state that the above information i.
W correct. l agree m comply with all city and county ordinances And slate laws relating to PERMIT ISSUANCE MECHANICAL HE
building construction,and hereby authorize represenwtives of thiscity to enter upon the
V mentioned properly for inspection puryoses. ALTER OR ADD TO MECH. CONSTRUCI'[ON'I'AX
agree mama emnify and kap harmless the ity of Cupertino against
liabilities. Jgmam, andexpensuwhicIt ywa cam gainstsaid City AIR HANDLING UNIT Pu 10,000 CFM)
tcnnenrye enf ting of this permit.
AIR HANDLING UNIT(OVI7R I(1,0n0 CFM)
Signature Ap canr/Contractor Dial EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE I MATING UNIT(TO 100,M)BTU) Data ReceiptA
Will the appli ant or future building crompmn store or handle hazardous material
as defined by the C nine Municipal Code,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER I W,(mD BTU) TTML.
Cade.Section 2553 ayJ
❑Yea 13 No VENTILATION FAN(SING LH RESID)
Will the applicant orfmure building occupant usceyuipmemonlevica which emit
BOILER-COMP(3HP OR 101.010 BTU) ISSUANCE DAT
hezardoim7
os air contaminants as defined by the Bay Amu Air Quality Marlugemanl BOILER-COMP(OVER 100,070 BTU)
DlAtr
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FP. P
I has rend the turrobus materials requirements under Chapter 6.95 or the v
CAIt I Inlga alth&Set CMA,Sections 25505,25573 and 25534. 1 ty to pond that
if the huildin ces currently base arenan" liamy res eibility to notify the pt.
cecupant of th - cors w '<h mos nor t of Ca ri tc of
Gecapane . z�/ 9 Cly r ,.
rlona an.gem Vale TOTAL: ISSUED BY: I T