25871 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMITNO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 25871
BUILDING DIVISION •,w,M.:re.'.!:'�BUILDING PROJECT IDENTINICAT10N� ,,
pSA
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALUA'II
LOT is
10 E:OggqCs� C-04
1 s elC
" 9 NKCONTROLa
•p CHITECT2NGINEER: LCNO: ADD SD/ Fc.r/ .11dr
CONTACT: PHONE: —at.f-, x:it -}* W�twvdrexve'Sy._,y 4s2n s 40\>a'�I'VYly�;'BUILDING PERMIT WFO�Y_�:'i". •.
QT.Y.�M1
BLDG ELECT PL
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL BIOBi$GYGTIpN�C�
I herchyeffirm theU em limned undttprovisims.f Choprtt9(cammuringwiN rter\YrY�y�s�i�� V
�00s.... Section 7000).(Division 3 of the Business said Pmfryeuions Cadge,and my license is in PANELS
Qin Idcrn rte veer c0a—^-T�Com s1 �6�0 / UP T02W AMPS ,,•!�y�/sPy�
<a D Conmctm 201-1000 AMPS W -
Ott' ARCHITECI-S DECLARATION A
8yz OVER IBM AMPS G PT I-- II li,s
•ZJ_Z�'71,G IYrmdcrstsnd mY Plans slWloduseulupublicrecmds.
F - SIGNS F.LEC TICAL
<::s Licensed Prafusimal
=,,a< OWNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC.
O y eVc.. 1 humby affirm Net 1 em exempt Tran Ne Courtrai License Law fm Ne
,1
XwtCLL Nfollowing reason.(Section 7031.5,Business soul Professions Cade:Any city or marry TEMP.MEIOR POLE INST. _ VX
F-,
'C"I which requires.permit d....meet.spar,improve,demolish,m repair any smeooue t
f } prim m its issuance.also requires Ne applicantorsuch pemJtto file a sipedstetement POWER DEVICES �..
J C tlw he is license pursuant to Nc provisions of the Connector's License law(Chapter gWIMMBJG POOL ELECTRIC VALUATIOIy�w
9(conwencing with Section]000)of DiviaionJof Ne Business meaPm(uaims Code)
.. r'`/
V_m that he iceeempt therafmm and Ne basis the allege amen,sion.Any violation of OU77-ETS-BWfTCHFS-FTJ(TURES
I_•Z}
Section 703 lS by any applicant fore pinhadijau the applicanawacivil pnaiy of
f—� not more them fits.hundred dollar($SM).
c,EQ [3I.uownerofNepmpny,mmyemployeeawiNwagmunheirwlemm .u.on. NEW RESIDENTIAL EI.ECRt _SQ.PT. STORIES TYPECONSTRUC IO!
a3— will dome work,eoulthe structure isnot inteademolfredfm We(Sa 7044,11uinss
and Professions Cade:The Convacears License Law doe not apply t.w owner of
properrylhms. vidm patsNemMve enu mssuchendkoroff .for We.If,
wnemployces.pruvidd Nn sucM1 improvemenuae nonimendeorotfcedforule.If, I, OCC.GROUP EUNI�however,Ne building or improvement is sold within one yearafCompletion.ibeowntt-builder will have the Wrden of proving Nat he did not build ser Improve fm popse oftile.)❑ Lasownaotthe Qty'Y,.> PLUMBGPrecomaFl.oaD zoNE
pee 7 an exclusively contracting e,Contrtonso :ixJ`iv^, `t, rry..7.;,,-.m+e•
Lt.. the project(Sec.70W,Businaa and Pro(euions Cade:)The Convector's PERMITISSUANCE
Limine law does nos epp1Y him owntt of pmopmry who bei Ids munprovu themed....,end
who conuactsfmwch pmjectswith.monomers)license pmsuwt to Ne Contrecmra -
Lim..elaw. ALTER.DRAIN&VENT-WATER(EA) :iJalv_T.�:,�:{a\FEE SUMMARY,`l;titi".�
❑ 1 sin exempt under Sec. ,B&P C fm this maven BACK FLOW PROTECT.DEVICE .ID
SANITARY Y N
Owntt Derc DRAWS-FLOORROOFAREA,COND. RECEIPT
M , ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iheeby affirm NeJ haveecenifireme afconsantosel(-inxurc,arecelfiue of RECEIPT#
_ Workers Cmnpnation frustration,me cenifie copy thereof(See31100.Lab C)which PER TRAP PARK FEE Y N
all mmployae'laul this permit. GAS-EA.SYSTEM-1 INC.40ITf1.ET5 RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 MA) PLANCHECK FEE �
[104adfiedrop,isharbyhorrusbad.
'fid may is file with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXFAWLION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not be completed lithe pans is forum hundred dallas(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or leu.)
I carry Net in the pAamwcc of the work fm which on,permit is rued,Iahall WATER HEATER WNENT/ELECTR
nm employ any Pamo in my amwrcr w an,to become subject m the WorkerPAID
Z Compemarionlawsof California. Dau WATER SYSTEM/IREATING Dae Receipt
AppOcwt
Z NOTICE TO APPLICANT:If,after making this Celfiea n of Exempdm,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
to
become, to t the Workers Compensation provisions of themus
labor Code,you must forthwith FEE eqL /�
a ; fbecomforthwithornbecome,wor N
with comply with such provisions is permit dull bma
IN,demand revoked.
1 CONSTRUCDON LENDING AGENCY SEISMIC FEE
1 herby affren that than is a construction Imdin,agency for the psfomunceof
DO the work for which this pmut u issued(Sec.3097,Civ.C.) L. ELECTRIC FEE
Leader's Name x:ala .. a.:�.>.vv«v;._. - -. :e ...s."+ N•�ie. "! PLUMBING FEE
U" F Lenders Address QTY.�'; '' MECHANICAL'PERNUT,.,Y'�W i t FEES:'a,
O U I rely that 1 have mad this application ad cam Net Ne above idomadm is -' MECHANICAL FEE
carat.l agree as comply with all city ser county ordinances and sone laws..elating to PERMITISSUANCE
bulldin vection,and hereb .amoriae me enatives of Nisci to emnery nthe
(� Z above-mentioned propny for i..potion purposes, y p ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We) S.m eve,indemnify and keep harmless the City of Cupnino against
liabilides,jdgmrnts,costs end expenses which may in my was accrue against said City AIR HANDLING UNIT(TO 10000 CFM)
in m ucnce of Ne parent. of this permit.
/ s AIR HANDLING UNIT(OVER IO.IXq CFM)
. ApplicadConwctor err EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.00(1 WITH one Receipt#
Will the aplicwt..future building mcupwa same or hadle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
u define by the Cupenim,Mwicipai Code.Chapter,9.12,end Ne Health and Safety
Code.Section 25532(a)1
❑Yes 13 No VENTILATION FAN(SINGLE RESIDI
ISSUANCE DATE
Will theappliuntorfuturebuddio,occupant ussequipment ordevices which emit BOILER-COMP(3HP OR IM."BTU)
haucim,air mmaminanu as defined by Ne Bay Area Air Quality Management BOILER-COMP(OVER Iffl,"BTU)
? Disma?
❑Yes ❑No NEN'RESIDENTIAL MECH.—SQ.PT. ` !
1 have mud the baurdous materials rcqulrements under Chapin 6.95 of the [o •� P
California Health&Safety Code,Sections 25505,25533 and 25534. I underund thin (�
if the building does not currently have a I.E.Raton;my rapnsibilitym notify Ne
oavpant of the rcqubemems which run od act prim to iuuwce of a Certificate of
Occupancy. (�! !
s
Owne,m.adimiced....t Date O ISSUEDBY: J /
OFFICE U