25455 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY'OF CUPERTINO - " P`RMD ND'
APPLICATION/PERMIT 'LUM NG-MEcuANICAL 25455
BUILDING DIVISION - BUILDING PROJECT IDENTDTCATION�, -
1WILDING ADDRESS: SANITARY U. APPLICATION SUBMITTAL.DATE
UNIT# LOT#
O NA 1 NE: CQ WOR'S NAME: LIC NO:
NIC CONTROL
AR /ENGI ER: LIC NO: D
;r
.CONTACT: PHONE: *}y'�r+`U .,eb 71.V'(+. zr- � t°'^-.�^:�.'•:,s :BUB.DING PERMIT INFO ' -
m.Jx, S"'CrtmsELI,,,Rtc Utz . �+�"'i` �n,. Nk:
BLDG ELECT PLUMB ME 11
PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
zd.Z Iherchyaffimmhatlam licensed under provisionsufamicr9(commencingwido
OO Section 7000)of Division 3 mine Business and Professions Code,and it.,license is in PANELS
I— full forme and effect.
=L W UP TO 200 AMPS
License Class Lic.Jr -v`v
^jH
Date Convector 201-Iqp AMPS .FT.FLOOR AREA 5lSQ.FT.
_yZ ARCHITECTS DECLARATION OVER I"AMPS
1 undersand my plans shall be tired as public records.
w SIGNS EIECITUCAL
Licemecd Professiovl
Xck< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
JyU1 hereby affirm than am excmp from the Cianommr's U.mam Law for me
=C)',N following reason.(Section 7031.5.Business and Professions Code:Any city or worry TEMP.METER OR POLE IN
which rcquims a Permit m construct.Aur,improve,demolish,or repair any somenum
'LYprior to its issuance,elm on,ims thcapplicant fnsuch permit file rimmed summon POWER DEVICES
z Q O that he is licensed pursuant to the provisions of the Contractor's License law(CWpmr
SELL9commencin SWIMMING POOL ELECTRIC VALUATION
(commencing 7000)or Division of the Business and Professions Cade)
y_y or that he is exempuhemfrom and the basis for theallegcd exemption.Any violnionof OUTLETS-SWITCHES-FIXTURES a
Z Q Section 7031.5 by my applicant for a permit subjects the applicant m s civil pe.my of L. 2
not more than Ove hundred dolma(5500). NEW RESIDENTIAL ELECSR —SQ.FT. STORIES TYPE CONSTRUCTION
z�� ❑ weak.
and therm numis otintnded widtwselfor theirml.compensation,
will dothcwork,and Ne he Coreisnotintrncouse o wdoes non (5«.to an ovmors
and Professions Cede:The vent eresm,Ld asho law does ., apply lf an owner is
of
pmpemploy ,promimpneesther«gan,5whoduessuehwoekhimselfar duough his OCG GROUP RES.UNITS
cown employ«s.provided thad
scom impnvemunure n e intmadorofferd far sale.B.
budder,the building or i en uproviniseold within one Lev of completion,the owrcr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sal<.1. _ m�; 7rk" ;;I PLUMBING PERmrrc?3e -or�K„p,,��`,FEE. i. 1. FLOOD ZONE APN
❑ I.m ref the pnpcnY•amexcluaively canvaninB wiNlian edconuecmrsm �ZAn •..,y�x-s#ar+•ra:."r.,W..c4:.:)Y.- a;'s4:a.
...in da,project(Sec.7044,Business and Professiuu Code:)The I---- PERMIT ISSUANCE
Licdm m law dr¢s not vppf y m arowner of properry who builds or improver theremt.ed
who ontrecu forsuch injects withaccommums)licensed puomemI=Conommr's c' r.xxg+� *. - V
License law. ALTER-DRAIN&VENT.WATER LEA) r+q e�,_rY rx- _FEESUMMARY'a'7.iv„���b,:
❑ I w exempt underSec. ,B&P C for this mann BACK FLOW PROTECT.DEVICE OUTSIDE -.S
SANITARY YN_
Ov neer DateRFCEIPT#
M
WORKAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA.COND. SCHOOLTAX YN
RECEIPT#
Wo Ihereby'Compe0tmihnlhave
ion,mafieam oedixintin eread(immm.m a bC.) whichne of FlXT11RFS-PER TRAP
Workers'Compenvtion lmurance oracmifiedcopY t0ereof(S«.3800.1ab C.)which PARK FEE RECEIPT# N
rn a0 employes under this pramiL GAS-EA.SYSTEM-I INC.4 OUIT-E6
BUILDING DIVISION FEES
Policy N
Company GAS-EA.SYSTEM-OVER4(EA) PLN:CNECK FEE �
❑ Cenifid copy is hereby fumi>hed.
❑ Cenifid copy is fled with the city impection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS* GREASETRAP SOILS FEE
COMPENSATION B4SURANCE
Tom s«tiomn«dmot be completed ifthe pend,is Jerome hundred dollars(5100) SEWER-SANITARY-STORM EA.208FT. ENERGY FEE
or loss.)
I certify Nat in the perfice..of she work for which this permit is issued,l staff WATER HEATER W/VENUELECfR
not employ my person in my mznne,so ss to become subject to the WorkersPAID
Compereation"vesof Califnxia. Date WATER SYSTEM[MEATING Dae Recdpt0
2 Applicant
NOTICE TO APPLICANT:IL after making this Cinificamof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
D L,, become subject to Ne Workers Compensation pravisiov of Ne labor Code,you man
= � fonhwith comply with such provisions or this permit shall be deemed meoked. BUILDMG FEE
U ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
3 Z 1 hereby affirm that there is a comouction lending agency for the performance of TOTAL:I ELECTRIC FEE
the work fm which this prnrvt is issued(Sec.3097,Civ.C.)
lander Name q:;l+T.?r,.'^'•.• ..'6' •�.•,�y e.� `•. PLUMBING FEE
F Lenucrx Address Q7'Y. .y yy.-", CHANIaCALL4PERNGT NEE:IS
U f certify that I have mad this application and sum that the above inforro man is MECHANICAL FEE
comes.Iagree to comply with all city and county ordinances and state laws mle0ng to PERMIT ISSUANCE
building con¢wetim,and h meby amhodre repmxnutives OHhis city to ermr upon the CONSTRUCTION TAX
Z above mentioned pnpetry for inspection purposes. ALTER OR ADD TO MECH.
... (We)ager«t p h.tesx the O of Cupertino against
liabilitios,ju odes many wayaccrucugainst said City AIR HANDLING UNIT(TO 10.000 CFM)
of the granI is permit.
_ AIR IIANULING UNIT(OVER 10.000 CFM)
Slgme D EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOO.OU)BTU) Date Reem #
Willthe applicant or future building Cap.,store in,handle haaurdous material HEA TING UNIT(OVER IW.000 BTU)
as defined by the Cupertino Municipal Code.Ch,mer 9.S2.and the Health and Safety
Code.Section 25532(a)? VE\TILATION PAN(SINGLE RESID)
El Yes ❑No ISSUANCE DATE
Will theapplicanmrfmnm buildingoecupant macquipmnumdevices whichemit BOB.ER-COMP QHP OR 100.000 BTU)
hazardous air contaminants as defined by the Bay Ama Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District?
❑Yes ❑No NEN•RESIDENTIAL MECH. SQ.FT.
1 have mad the haN
rnous materials requirements under Chapter 695 of me AUG 13 �ggg
Califmmiu Health&Safety Code,Sections 25505,25533 and 25534. 1 undersand Nn r
if the building docs on,currently have is mnant,that it is my responsibility m notify Ne Y LIr'k.l tkrl,�J1VV
occupant of the requirements which must tc met prior m issuance of a Certificate of
Occupancy.
Owner or vu0mrined agent Dae TOTAL: ISSUED Bl
OF I