25423 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO vBRMrr No.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDEN'TIF'ICATION 5 /I O
J L� J
BUIL DING ADDRESS: / a(/�, J sf `Ip SANITARY NO. J APPLICATIONSUBMITTALDATE
f0 !!;-7 (�C G/1 I'�OOC/r bl' Vle UNIT LOT# Q-L-t
O 'RS NAME: - P{ONE: CONTRACTOR'S NAME: LIC NO:
QYtrSi ;G AIV.
el.5 Go�hB "lc coNlRol.#
a N+e s c+pas i e S x-181 i fi 9'
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H/ CT/ENGIN LIC NO: ADDRESS: , p
(P ire vG ec tM •P 1LJSzq M clso +nl Sa-ijos c ❑ 3"v
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
$LDG GLL_'CI'_ PLUMBC
PERMIT ISSUANCE �� TWQ- 1EIT
LICENSED CONTRACTOR'S DECLARATION pPL1ANCES RESIDENTIAL �� JOB DESCRIPTION
odez I hereby affirm that lam licensed underprovisionso(Chapter9(commencingwi[h
WOO Section?Quad of Division 3.f the Business and Prolfession/s�Code.and my license u in PANELS /^—
<Z full foe Cl vaeffort. a Lic.It `�k!'D RP D /// '/�C'P.J'(i1sJ1DS
f<% License Cl{3,s L Conuaclor4O UP T0200 AMPS I)(,
vita Dole Y�� �� 201-1000 AMPS
— SQ.FT.FLOOR AREA S/SQ.FT.
OZ-0ARCHITECTS DECLARATION OVER IOOOAMPS 1 r�Q
O Z—C I undersand my plans shall be used as public ramds. 'I
F,to F W SIGNS ELECTRICAL
CY;F' Licensed Professional
amot< OWNER-BUILDER DECLARATION SPECIAL CIRCUCOMISC. F�
XOaU 1 hereby affirm Ihal I am exempt form the Contractor's License Law for the 6/
u1'3 tat followingrcood.Section?031.5,Businexsand Professions Cmde:Any utyorcmeely TEMP.METER OR POLE INST.
a wM1ich mynircx n pcmil to cmnswd,alcor,improva.dearmi so or mpair any structure
"7 rim m its issuance,also the applicant for such permit file a sinedsamment POWER DEVICES
p requires pp pe g
K OO that he is licensed pursuant to the Provisions of the Gnmaclors License Law(Chapter SWIMMING POOL ELECTRIC
aao� 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) VALUATION
W_,Z or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OfITLETS-SWITCHES-FlXTURES
F Z Q Section 7031.5 by any applicant for a permit subjects the apPlicanuo a civil penHty of
ra Z O not marc than five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
W 3—'' will❑do the work,and the svucture is not intinded or offered Orr sale(Sam.7044,Business
and Professions Code:The Contractors License law deer not apply to an owner of
properywho boildsorimproves therenn,and whodassuch work hintulfo through his txC.GROUP RES.UNITS
wnemployees,provided that suchimprovemm
esara not immadedoroffemdforsale.IL
however,the buildingor improvement is sold within one yearefeempledon,the owner- T
builder will have the burden ofproving that he did not build or improve for purpose of
sale.)m/(as ro(the Property, exclusively cnnlrn<ling with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
instruct Ore pmjal(Sec.7644,Business and Professions CudeJ TAe ConmUors
License Law does not apply loanmenermf mnoty who buildsnrimprovest'10=and PERMITSSUANCE
who contracts for such projects with.crmracmr(s)licensed pursuant mrhe Convectors
License Law. ALTER�DRAIN&VENT-WATER(' ) _ FEE SUMMARY
❑ lamcx plunde .B&PC�rtreyon BACK FLOW PROTECT.DEVICE ,iMDEFEE5i
SANITARY YN
QI A Data RECEIPT#
WdRKMAN COMPFN ATION DECLARATION DRAINSFLOOR,ROOF AREA.GOND. SCHOOLTAX YN
�
❑ Ilio off that l have eteriGwteofconxm to self-insum,rracerificamof Fl%TURES.PBR TRAP / RECEIPI'p
I Weskers Compensation Insurance or a certified copy lhermf(Sec.3800,Lab C.)which PARK FEE Y N
covers all employa's under this permit. GAS-EA.SYSTEM-]INC.,
OUTLETS HT:CF.IIT#
policy# BUILDING DIVISION
Cometray copy is hereby famished. GAS-FATE
.SYSM-OVER4(EA) PLANCHECK FEE
❑ a `
❑ Carolled copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING HE
Cl IFICATE OF EXEMPTION FROM WORKERS' GREASHI RAP SOILS FEE
COMPENSATION INSURANCE ��II
(This section need not be completed ifthe permit is for one hundred dollars�Jll SF, ER SA AR - TOR F"1'. ENERGY FEE
or less.) •�•• .+•• a••
I certify that in the performance of the work for which this permit is issued stis11I�1WATI]t :AfiER WNENI'2LE
not employ any Person in any meaner so as to become'objet 1.the W PAID
Compcnmtion Lowsof Cellforda. DateWATT! Y R Date Ra
zZ Applicant
C) NOTICE.TO APPLICANT:If,after making this CcNOnm of Exemptioi,you sho TE NF.W Q.FT. TOTAL:
Tail becomewill m the Workers ro
Compensation Pv sons of Ne Labor Crhe;yrumusl
� � forthwith comply with such provisions o this permitshallbe dammed revoked. BUILDING TEE --il
UJ (, CONSTRUCTION LENDING AGENCY SEISMIC FEE0. r `
I hereby scrim Box there is a construction lending agency far the performance of -
U O the work for which this permit is issued(Sm.3097.Civ.C.) L ELECTRIC FEE
LL Lenders Name PLUMBINGPEI?
Lender's Address QTY. MECHANICAL PERMIT FEE
O U I certify that I have read this application and state that the above information is MECHANICAL FEE
�" PJ cored I agree in comply with all city and county ordinances and slate laws relating to PERMITISSUANCE
F" V) building consonction,and hereby authorize representatives of this city to enter upon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hminless the City of Cupertino against
cr
liabilities,judgments,cove,and expenses which may in any way acue against said City AIR HANDLING UNIT(TO 16.060 CFM)
in consequence of the greming of this permit.
AIR HANDLING UNIT(OVER 10,0100 CFM)
Signamrc of AlepliconVCommaor Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Retailer If
Will the applicant or future building occupant store or handle hazardous material TOTAL
as defined by the Cupertino Municipal Code,Chirpier 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Scene.25532(.)? VENTILATION PAN(SINGLE RI3SID)
❑Yes ❑W
•• ISSUANCE DATE'
Will thea licamorfuture buildin cu tusee tordevices whicheink BOILER-COMP QUIP OR 166,060 BTU) pp p
PP ga. pun yuipmcn � W p D; •
hazardous
air
contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,606 BTU) j
Diahia1P ❑ ad NOV
� Yea NEW RESIDENTIAL MECH. 5Q.F1'. � 171993`
I have mad the hnarerus mammils rcgairemems under Chapter 6.95 of the /� ,
California Health&Safety Code.Sections 25505,25533 and 25534. 1understand that CITY
Uf• (;Up
ifthebnilding x not curren0y ham.anent,that it is my responsibility to notify the CNI 5
reception of l qu 'or to issuance o a C rifiram r[
Occupancy.
Owner ora agent Donei A /� ISSUED BY:
OFFICE