25894 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.M.F.CrRICAL PHRMI'I'NO.
25894
�
BUILDINGDIVISIONPLUMBING-MECHANICAL
vlslory APPLICATION/PERMIT G J 4
BUILDING PROJECT IDENTIFICATION 5�� A
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
UNIT# LOT# P 15332 ��
OWNBRS NA L: PHONE: CONTRACTOR'S NAME: .ICNO:
N V2 f1 `p N/C CONTROL#
,RCHI'I'ECI'/I?NGINEEN: 6 LIC NO: ADD 4S� M Vry m 1 ❑
AIONTACT: /,�/ v,-7— 732 Q'r ELJE=C9:�RRI.C,PERMIT YFEE BLDG BOELECT
G PE RMITBNFO MLCH
U PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
P4Z N
00 Section 70001 of Division 3 of the Business and Professions Code,and my license is in PANELS
r{ full force las effect.
QZ License Class hic.p 675 7�D UPT0200AMPS
rFi,<y Date contractor 201-I(XIOAMPS
ZOin�p ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA SISQ.NT.
O Z^W I understand my plans shall he used as public records.
r_rn�BJ1 SIGNS ELECTRICAL
CQ Licensed Pmfm,ionel
==< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O y F I hereby affirm that I am exempt from the Commmor's License Law for the
W 3 a m following reason(Semon]031 5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit m consuom,offer,improve,demolish,or repair say"comme
h :F priorm its issuance,also requires the aWlicamforsuch Permit o file a signed statement POWER DEVICES
0 that he is license f,mmum m the provi,mos cif the ContBstne.License Law(Chapter
9(cohunencing with Section 700lDivision 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
tiyC_a, mthat he is exempt therefrom and the basis forthe alleged exemption.Any violation of DUTLLTfS-SWITCHES-IIXTURGS
��a Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
$ not more than five hundred dollars(SSW). NEW RESIDENTAL BLELTR _SQ,FT.
N 22 ❑ Lasownerandmespentum is not
Business STORIES TYPI?CONSTRUCTION
a 3'-° will drglCWonsCde The Conlan License Law(does sale not
to an owner
and Professions Code:The Conuemon.License Law does not apply ff an owner of
property w,ces.provided
troves daemon.and whodms such work himself mformle.his
I ees,pmvided thatsuch int t Y t ddurofferdforsale.If OCC. N P RIiS.UNITS
amp oy provarxn sant not men
however,the building hr improvemcm is sold within one yea of completion,the owner
builder will have the burden of that he did not build or int rove for a of TOTAL'
proving p purpnc
ale.).
❑ hes owneroftheproperty,e(n exdusivelycommcting with licensed convanonm QTY. PLUMBING PERMIT FEE FLO ZONE AIN
construct the project(Sec.7M,Business and Professions Code:)The Cs,ntrmmrs
License Lawdoes not apply matownemfpramy who builds or impmvesthercon,mad PERMIT ISSUANCE
who conforms forsuch projects with a commands)licensed puruantto the Conuacmis ALTER-DRAIN&VFNT-
WATER(EA)
License Law. P MAR
❑ 1 Bn exempt under Sec. ,B&P C far this reoaon BACK FLOW PROTECT.DEVICE
SA ARY N
(Owner Dote DRAINS-FLOOR,ROOF,AREA,COND. HCEI
WORKMAN COMPENSATION DECLARATION S OOLTAX Y
❑ lherebyaffimnMtl Mveaeerifinteofcons tto Blf-imum,oremnifimBof FIXTURES-PER TRAP RECEI
Wisdom Compensation lnsuranceora cenified copy thereof(Sec.3800,Lab C.)which RK FEE Y N
covers alt employee's under this permit. GAS-EA.SYSTEM- INC.401H.HTS
Policy R ION
FD EES
Company GAS-EA.SYSTEM-OVER 4IHA) P1. CHECKILF.
❑ Certified copy P hereby fumished.
❑ Cmifid copy is Eld with the city inspection division. GRF.ASFJINDUST'RL WASTE INTERCEPTOR GRAD]NE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASLTRAP S011S FEE
COMPENSATION INSURANCE
(This section^had not be completed if the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY MR
or less.)
I certify that in the (the work forwhich thiapennit isicsued,lshall WATER HEATER WNFNIBLF.CIR
not unploy any m order sq#nt bac=m9 mbjeT11 Workers' PAID
z Compensation Lew Ceb D (r 1eI WATER SYSTP.M/IRFATING Data Receipp
Q pPPlicant Tr
Z � NOTICE TO�.ICANT:If,aRermeking Ms Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
F v) becomesubjmno the Worm',Compensation provision ofihe labor Cattle,you must
ronhwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FISH
7- 1 hereby affirm float then is a concoction lending agency for the performance of ELECTRIC FEE
V O the work for which this Permit is issued(Sec.3097,Civ.C.)
Lenders Name PLUMBING FEE
O U 1< ndeta wddreaa QTY. MECHANICAL PERMIT FEE
1 certify that 1 have reed this application and state that the above information is
>., 0k correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEC
F' y building concoction,and hereby amhorize representative ofthisciry theater upon the CONSTRUCTION TAX
V Z above-memiond property fm impaction purposes. ALTER OR ADD TO MECI I.
(We)agree t sev mdcmnify and keep ha(mles a Ciryof Cupertino against
Imbiliti judgment randox seswhichmay' anyw.,..c,mn.Isaid Ciry AIR HANDLING UNIT(TO IO)Np CFM)
enc uerace of granting is 1.
AIR HANDLING UNIT(OVER 10,1100 CFM)
Sign t of ApplicanJContractor pant EXHAUST FOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOQOOO BTU) Date Receipt
Will the applicant or future building occupant smrt or handle hazardous material
as defend by the Considers,Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.01)0 BTU) TOTAL:
Code,Section 25532(e)7
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will sur eariemnhrduan building by tummy equipment Quality
BOILER-COMP(3HPOR 100,000 BTU) ISSUANCE DA E
�aatdmma air conmminanu as defused by the Bey Ante Air Queliry Management
)iamin7 BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. P A D
I have mad the hazardous mamriels requirements under Chapter 6.95 of Ne �cY
Califortda Health&Safety Code.Section 25505,M533 and 25534. I undersand that ,ass-
if the building does not currently have a Bram,that it is my responsibility to notify the 1994
mcupant of Ne oxymements which must be met prior m issuance of a Certificate of
Occupancy. Cl/Y Ll VI
Owneror emhorized agent Dale TOTAL: ISSUED BY: (-
OFFICE