25373 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - " PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25373
BUILDING DIVISION BUILDING PROJECT-
IDENTIFICATION
BUILDIN AD�RgSS: LOTk SANITARY NO. pPPLICATIONSUBMfITALDATE
N /�/1/snW/�lO O PHONE: CONTRACTO `NA�MO A LIC NO:
s/O NIC CONTROL p
,• ARC tECAM LIC NO: ADDRESS: ''''^^ n ❑
CONTACT: PHONE: ;^ 1 AEz.;>i~b� BUILDING PERMIT INFO
QTY „g,iA EL RIICaPERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I here alRrmthel l amlicenxd under iansof C'h 9(commencin iN IOB DESCRIPTION
G0.'Z M Pm Pr voter gw
u100 fSection all
it of Division Jof the Business and Professions Cade,and my license is in PANELS Fq W full force end effect.
<z I.icrnu Clsss LIC.M UP TG 200AMP$ �
1yF--6 Date000 Convector 201-I"AMPS
ZOrn� �j�SQ.
yZ ARCHITECTS DECLARATION OVER 1AMPS SQ.FT.FLOOR AREA FT.
I
O Z'-G I undersand my plana shell be used v Public recitals. [n//I��I L E D '
r` , SIGNS
PECIA ELECTRICAL g V p-� P lJ T IE
Licensed Professional
C 6 that
I.-B exempt
from
m the CoATION SPECIAL CIRC'UITlMISC.
st V I hereby uffirn Not 1 nm exempt from Ne Convectors License Lew for the
o 3 u hfallowing reason,(Section 70I L5,Business end Professions Code:Any dry.,county TEMP.METER OR POLE MST.
ON which reproves it Permit to construct,alter,improve,darn dah,of rcpar,any svuctuse
Y� pnorto its issionce,also requires be applicant for such Manor file a signedsmmment POWER DEVICES E
W <pz Nat he is licensed pursuant to the provision of the Convector's Lirrnx Law(Chapter
L p'�oLL 9(commencing with Section VOW)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUA
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
L.ZQ Section 7031.5 by anyvpplicant fora permit mbjects the applicant toe civil Penalty of OUTLETS
-SWITCHES-FIXTURES
^� nor more than five hundred dollars($500).
K ❑ Luowork,ard epmpmy,ormyemployeeswiNwegesntheifsole compematiun,
NEWRESIDENTIALELECIR _SQ,FT. STORIES TYPE.CONSTRUCTION
y will dothe wons end the he Careiselotimmdedor.fwdoes not apply
in a Barters
and Professions Cade:The Convectors Litaue law deet not apply w an owner of
property who buildrafimpow ea Nereon,and whodoessuchwork himselforihroughhis
OCC.GROUP RFS.UNITS
veneer,thees,p building
orINalve mmprovld wifarenayearincmpletiod for own If,
however,the building or improvement is sold within one yam of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build m improve for purpose of
We.). kwWk.
❑ I,es awnerof the property,amexclusivelyconuneting with licensedconnuctonm Q�Y:. PLUMBING PERMIT FEE FLOOD ZONE AIN
comwct the project(Sec.7044,Business and Professions Code:)The Connectors
Licame Law decant apply romownerofpmMywho builds.,improaea then...and PFRMITISSUANCE
who contracts fomuch projects withacoormanos)licensed pmeuant on the Connmine.
License Law. ALTER-GRAIN&VENT-WATER(EA) PCE SUMMARY
❑ 1 am exempt under Sec. ,B R P C fm this reasongpCK FLOW PROTECT.DEVICE - TSI
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT It
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ Ihereby off that l have a certificate mcomsenn to self-insure,or a certificate of FIXTURES-PER TRAP RECERTp
W.rkers'Compensationimumnceoracardfiedcopythcreof(Sco.3800,1ab C.)which PARK FEE Y N_
covers all employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RDC
Policy g BUILDING DIVISION SION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Candied copy is hereby famished.
❑ CenifiM copy is filW with the city iapeclia division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION WSURANCE
(This mcdonnednmhe completed Holes permit is foronehundrtddollars($IN) SEWER-SANITARY-STORM EA.200FT, ENERGY ME
or lass.)
I certify that in the performance of he work fm whichthis permit is issued,I shun WATER HLATF"R W(VCN'T/ELECTR
not employ any person in any manner so u 1.become subject m the Workers' PAID
Compenxdon Lawsof Cdifamia. Date WATER SYST9M/1'REATING Date Receipt#
Q z Applicant
z NOTICE TO APPLICANT.If,eller making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workers Compensation provisions of the Labor Code,you must BUILDING FEE
forthwith comply with such Provisions m this permit shill be deemed revoked.
W (:] CONSTRUCTION LENDING AGENCY SEISMIC HE
I hercb afirm that there is a construction leading for the Perfoman f
UO TOTAL: ELECTRIC ME
the work for which this Farrar n nsad(Sec]09'1,Ons CJ
0 �
Letalre.Name ) f
Lenders Address Q7�Y pi. MECHANICAL PERMIT � FEE PLUMBING FEF"
sem.. I modify that 1 have read this epphcava and stare that the above infomuua is '( AC` v '2' MECHANICAL FEE
r a correct l a gree to comply with all city end county mdinaces and stem laws mining to PERMIT ISSUANCE
�+ y building convection,andhemby authadze reprtxnmdvasofthia city to Iner upon the CONSTRUCTION TAX
L) 7 above mentioned Property for inspection Porpoises. ALTER OR ADD TO MECH.
C. (We)agree to save,indemnify and kxp hemdess the City of Cupertino against
liabilities,judgmerns,cmts andexpemes which mJe�'�any weyacerueagaina said City AIR HANDLING UNIT(TO Io,"CFM)
in come,m c ffee tin Nie t.1/'�/s
r�7 AIR HANDLING UNIT(OVER 10,0)CFM)
So sof Applicant,Commcl f m EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOg000 BTU) Dune Receipt0
Will the applicamar forum Wilding occupant Mort orhandle basardom mamdd HEATING UNIT(OVER 100,000 BTU) AL.
m defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Cade,Section 25532(v)] VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will theapplientorfuwmbuildingmcupmtuxeyuipment.,devices whichemit BOILER-COMP OFF OR MOM BTU) '
hazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COM?(OVER IMM BTU) P A ' D
DistrcR
❑Yes 0 N NEW RESIDENTIAL MECH. $Q.FT.
I have red the hazardous mammals 5505.2mema under Chapter imm nil the JUL `Z 9 N
Cilie building
Sermons25505,2553]and 3ponsi Iitytonad Net u
ifcubuildingdoestrotunremlyhaveamna, et it iii myssuance ofiry ronmify Ne
O cup an of Ne requirements which most be met prim m issuance of a Cenificam of t11 T y f ``UC\
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE