25543 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILDIM1G.ELFiLTRI A PERMITNO.
APPLICATION/PERMITPLUMBING-MECHANICAL 25543
OUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUII.DINSe� ��� P�, 11NITp LOTM SANITARY NO. AIRLICATION SUBMITI'ALDATF.
OWNH NAME: IU{Jli;a..A C N R' MI:: LIC NO:
115 NIC CONTROL p
RCHITBCI'R:NGINEER: LIC NO: ADD ESS. �L ❑
CONTALT: PHONE + '-I "r T J"' BUILDING PERMITINFO
II HI:eEQIRIC PERMIT ME
BLDG ELECT PLUMB MECH
PERMITISSUANCH - ❑ ❑ - ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESC 1 NN
pnyy I herebyaffirm that lam licemud undcrprovisiovofChapmr9(contmencingwith `-
Section 7000)of Division 3 of the Business and Professions Code,end my license is in PANELS // V
pZ, Liecrfall a,Classce and fleet. UP TO 2W AMPS
< f.icenu Class Lic.p
un<w Data Comport., 201-1000 AMPS
F h ARCHITECTS DECLARATION SQ.FT.FLOOR AREA SJSQ.FI.
OOZZ-O 'I understand my plans shall to,used as public records. OVER 1000 AMPS
r-4 E m SIGNS ELECTRICAL
�j Licensed Professional t
OWNER-BUILDER DECLARATION SPECIAL CIRCUMMISC.
P�OaE I hereby affirm that Lam exempt from the Convacmr's License Low for the
1t+1.4 o n following reason,(Section 7031.5,Business and Prof
essions Code:Any city or county TEMP.METER OR POLE
which requirea pe,adt m construe,slur,improve,demolish,or repair any structure n e
`nY� oeq
Prior its issuance,also requires the oppIcarian l icant Ician p,rmiuo file a signedamtement POWER DEVICFS N
L
CI;:
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
o.
OK 9(commencing with Section 0000)of Division 3 of Ne Business ad PmfessmosCode) SWIMMING POOL ELB RI ; VALUATION
o or that he is ase , on andtne basis far rheall,edesem,nom.My violation of �.
1. a
Section 7031.5 by any applicant for a permit subjects the applicant to u civil penalty of OUTLETS-SWITCHES.FIXTURES M
^� not more then Five hunArul dollar.(.8500). k•�o
tY m ❑ I,asowncrofthe n NEW RESIDENTIA P,I.EC S'f IES TYPECONSTRUCTION
prnpe y,armyempinymowithwagesutheirsolecompensa[Ion,
a3— will data,work and the swctme isnot intended aroffered forsale(Sec.704q Business
and Professions Code:The Contractors License law does not apply to an owner of
propertywho builds orimproves themon,and who does such workhimulforthrough his OCC.GROUP' RPS.UNITS
own employees,provid,A that such improvements are notimended mothered hoards,IL
however,the building or improvement is sold within one yemofcompletion,the owner- TOTAL:
builder will have the burden of proving that hand not build or improve for Purpose of
n
I,asowner.rlh,pmpeny,emcadusivelycnmructing wiN l hamodcnnmaaomn QTY, PLUMBING PERMIT FEE FLOODZONH APN
wet the projm(SC<.7D14,Business and Professions Code:)]he C.ntrumr'a PERMITISSUANCE
v cense Lew Ams not applyin on owner of prapeny w h.bur Ids m improves thereon,aaW
Whoe.ntraeb forsuchpr.jects with acomractons)licensed paramount the Comratmre
License Luw. ACIRR-DRAIN&iVEMI'-WATER(FA) FEI?SUMMARY
_
❑ 1 sat exempt under Sec. ,B&P C f n this tensor BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX V N
❑ IhercM1y affirm lhatl have acenifbme of d.nunn.self-insure,oremrtifce[e of FIXTURES-PER TRAP RECEIPT g'
Worken'Compensatinn Insurance ma cenifiai copy lhemof(SecJg00,Lan CJ which PARK FEF. Y N
covers all employee's under this permit. GAS-EA.SYSTIiM-1 INC.40lITLLTS RECEIPT N
Policy p BUILDING DIVISION FEES•
Company GAS-EA.SYSTHM-OVER 4(EA) PLANCHECK FEE
❑ Camfiedcapy is hereby tumishm.
❑ C,mified copy is filal with the city inspection division GREASFJINDUSTRL WASTE INTERCEPTOR GRADINGFLE
CERTIFICATE OF EXWi PTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not he completed ifhe proton is foram hundred doJimp I0B SEWER-SANITARY-STORM EA.200FT. ENERGY FEF.
o,lora.)
Ic,my that in the performance of the work for which lhisperunit is issued,Ishall WATER IIBATFR W/VI:NT/L'L13CTR
not employ any person in any manner an as to become subject to be Work.% PAID
C..'austi.n taws.f Califomu. Date WATER SYSTRIA(REA'I'ING Date Receipt N
O 2NOTICE'I'O APPLICANT:If,after making this Certificate of Esem t should NEW RESIDENTIAL PI.MB. SQ.FT.
p ion,you s o TOTAL:
.>r becarre hwithc replyct the Worker's Compensation prmisiorel be es,thermal
Later
moked.you must
�i 7 forthwith comply with such Provisions or this permit ahall4 Jeemcd revoked. BUILDING TEF.
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
5 1heresyaffirm permit
is acirl(Se.3lendingagency fm the pedortnencc of TOTAL: ELECTRIC IEE
the was.for which this pemtit is iuucd(See.709],Civ.CJ
Nunn
Lenders� Addr PLUMBING FEE F Lender. ddrc.. - - QTY, . MECHANICAL,PERMIT' FEL
V I certify that I have mad this application and state that the above infomradon is
correct.I agree to comply with ell city and county ordinanms and state laws rehdng to PERMITISSUANCE MECHANICAL FEE
(� building construction,and hereby euNotize representatives of this city to enter upon the CONSTRUCTION TAX
U 7 shave-mentioned property for inspection purposes. ALTER OR ADD TO MECI I.
�-t (We) area to save,indemnify and keep he mless me City of Cupertino against
Iiabi Ho judgments,cosuand eispensen which may in any way meme Nrirtal said City AIR HANDLING UNITCTO 1 U."CFM)
ere.Utnegrvn in .(this Permit.
AIR HANDLING UNIT(OVER to,"CFM)
Sgnameofd P cm 'ompoc Dam HXHAUSTHOOD(W/DUCT)
PAID
HAZARD Ug MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt N
Will the applicant or future building occupant more or handle hazardous materiel 111iATING UNI'1'(OVf?R IW,11L`0 B'fll) ]'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health send Safety
Code.Section L5532(a)?
❑Yes ❑Na VENTILATION FAN(SINGLE RfSID)
Will theepPlicanmrfmurebuilAingoccupant useeyuipment ardevices whichemit
BOILER-COMP(3HPOR 100,0001311.) ISSUANCE DATE
turned.air comnminants as defined by The Bay Anse eAir Quality Management BOILER-COME(OVER 100,000 BTU)
�tatr;rt7 -
11 Yr, 1 p
Yer No NEW RESIDENTIAL MHCII. SQ.lel'. P A
I have read the hmatdom materials.1marmema under Chapter 6.95 of the - �
if the building
Ing lthdo&Safety Code,have.
ms 25505,r it is and 25574.I ily to rtertd fast
,he ,t 19
ifthegJ cpdoca .tsw which
oma,are itis my m..msiof. to nficide of 4
occupant of tluc rcqulremems whidi nater be are prior to issuance of o Cenificele of f% }-s� 01
Occupancy. CII I
Owae,.r authonudagm, Date TOTAL: ISSUED BV IyL7
OF
' ,VALENTINE CORPORATION- GENERAL ENGINEERING CONTRACTORS
111 PELICAN VyAY •,SAN AFAE , CA I j
I 1 , ,
! BY SUBJECT �� SHEET �0= .; !
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