25157 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-El:ER PERMIT No. 25157
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTALDA'H?
�ti I1NIT# 1.01'#
OWN" SNAME: J �� P ONE: CONT CTOR'SNAM'' LIC NO: NIC CONI'ROLp
RCHITECT/EIJG NE ER: LIC NO: ADDRESS: a•aaL I.' --4d ne El
��.� coNTACT: PHONE: k k•q � 'Ffl •a' BUILDING PERMIT INFO
Qa'Yx 1#..* 5..1$LF.,CTRICSPERMIT. k,, FEE
6. -�w BLDG :CECT PLUMB MECH
PERMIT ISSUANCE rl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TJ
QWz I hereby affirm that l am licensed underprovisiouofaapwr9(commencingwiN JOB DESCRIPTION
IY00 Se a7flo o(Division3ofthe Business and Professions Code,and my license is in PANELS
tK W all force and effect. 1
G W License Cluss Lic.# UPT02MAMPS
N5y Date Cnntruotor 201-1000 AMPS
ZFOy� ARCHITECI'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall be used as public records.
F-W SIGNS ELECTRICAL
hF7--1 Licensed Pmfessional
d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�y(0 4U 1 hereby M.that I amexempt from the Contractors License Law far the
W'3 tr,ma following reason.(Sectinn7031.5,1amineea and Professions Code:Any city or county TEMP.METER OR POLE INST.
BOJwhich requires a permit 1.coca owt.ul art,improve,demolish or repair any structure R 9
;!(>-n prior m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
m G 0 that he is licensed pursuant to the provisions of the Conuacmes License Law(Chapter
dao 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y M,, ar that he is cxempnhemfromand the bni,for Nc alleged eacmptimn.Anyvimadonaf
F.Za Section 7031.5 by any applicant foraOUTLETS-SWITCHES-FIXTURES
permit subjects the applicant to a civil penalty of
Pat mare than five hundred dollars yemp.
Drape Y Y D Y 6 penation, NEW RESIDENTIAL F.LECfiI _SQ.FT.
❑do the
wrk,ande cl,orm emeneeswithere forsalei(See.coat STORIES TYPE CONSTRUCTION
y3� will dmhewons Code:eslie CoPsnotintendese La do es rot apply to an Business
end Professions ldsor impr Contmaorx License Lew docs not apply to an owner of
ownfounenywycesho ,pdonr ed that esfeemrovemr.and ted mtch work dMoroxlfor through
redo.I,
employeesildingedthutveMmpnwementsareneyearndedoroenon,foredo. OCG GROUP RFS.UNITS
builder
will ave the burden
of pmentishat he did Put
buil,or improve le.). will have th<huNen of proving that he did not build or improve for puryau of
ale.).
❑ I,c, he prmfthepec.704am Business
and contracting withda:)*Me Cminmrsto QTY: PLUMBING PERMIT FEE FLOOD ZONE. APN
Licenser the project(Sec.oono4.Business and Profession Coda:)improves
Conion.ans
whoca Lawdoas such
apply manoh a conmropeny who
nsedpurs impro the fiverContra,ina PERMIT 159UANCI?
whence Lcts for xuehprojwte withacmntrennr(s)licensed pursuant to Convector's ALTER License Law: FEE SUMMARY
❑ 1 am exempt under Sm. ,B&P C far this onwn BACK FLOW PROTECT.DEVICE OUTSIDE FESS
SANITARY YN
Owner Data RECEIPT'#
n WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL TAX Y N
1 hereby affirm that I have a cenif¢me Lifconsem m xlf-insure,lir a certificate of RECEIPT q
FIXTURES-PER TRAP
t Lirkcre'Compensminn lnsurmmce ora ceniliul copy thereof(Seo.3g00,LebCJwhlch PARK FHN, Y_N
coven all employ.x un der this permit GAS-EA.SYSTEM-I INCA OUTLETS RECRUIT
Policy# BUILDING DIVISION ITES
Company GAS-EA.SYSTEM-OVER 4(EA) PLAPCHECK ITB
❑ Cenified copy is hereby famished.
❑ Certifiedcmpy is filed wif the city inspaefon division. GREASDINDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS F"H
COMPENSATION INSURANCE
(This section need mebe completed ifthe permit is forma,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEB
less)
I certify that in the perfmorn mea of Bar work for which this permit is iswed,la hall WATER HEATER WNENT/ELECTR
not employ any person in say momma so an;to become subjcet an the Worker' PAID
Z
Compensation Lawsof Califom{a. Date WATER SYSTEMITREATING Date Receiptp
O O Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V1 become subject to the Worker's Compensation provisions of the Labor Code,you must
�i 7 foMwith comply wi tb such provisions or this penrdt shall he deemed revoked. BUILDING FEB
0. Q CONSTRUCTION LENDING AGENCY SEISMIC TTI?
z I hereby affirm mundane,iso comVuction lendingagency forthe perfixtro sof TOTAL: ELECTRIC FCL?
U O the work far which skis permit is issued(Sec.3097,Co.C.)
I<nders Name
OendrU I
r's Address QTry; Ir MECHANICAL PERMIT' FEE PLUMBING FEF.
U I cenify that 1 have Paul this application and sate that the above information is Y S
GWn correct.Ingres,,comply withhil city and my ordinances and state laws reining mPERMIT ISSUANCI? MECHANICAL FEE
y buildingconsmruci ,undhcrebye ori rcsenmtivex.fthincit,martertipoalhe
U z above-mention
am,
for ins u n u ALTER OR ADD TO MECH. CONSTRUCTION TAX
(W gra "y p hasmless the City of Cupertino against
Imbiliti ,j dg nts,coatsandex ich may in any way,accrue against said City AIR HANDLING UNIT(TO 10,00E CFM)
in coax o the grand i Sof i m447 J .
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature, Applica tat Date EXHAUST 110011(W/DUCT)
PAID
71 ARDODS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dote Receipt#
Willthe app im P future building occupant store or handle hmardous material
u defined by the Clpcnino Municipal Cade.Chapter 9.12,and the Hart,and Safety IfETING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532nd?
11 yes 0N VENTILATION PAN(SINGLE RF.SID)
Will theepplicum nrfuturebuilJingomccupam use equipment nr Aevicee whichemit
BOILER-COMP(31 In OR 100,000 BTU) ISSUANCE DAT
haznotaus air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District? w
11 ye, ❑No NEW RESIDENTIAL MECH. SQ.Ef. f pp�� A Y D
I have read the hazardous materials requirements under Chapter 6.95 of the
occatHealth o Safircone Code,Sections he Piet 25533 and 25534. 1 understandehat ����
Californiathebuildingltmics Putcurrently base atenant,5, itis and
mitonotify the s
the building
of We rut Put came which must he mat pilo,to issuance of n Gu,imiry he
of
Occupancy. cl ` k _�
Owner or authorized agent Date TOTAL: ISSUED BY: