25233 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT I.O. ^
APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. /A/�PPLICATIONSUBMITTALUATE
10-111 I-A O UNIT# LOTH IQ/-21--R V�
OWNERS NAME: 410NE: CONTRvCIOR'SNAME: LIC NO:
M x/.w v N/C CONTROL p
•ARCHITECT/ENGINEER: LIC NO: ADDIS O f Z
AT104 5/t
CONTACT: PHONE: 10
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz I hereby affirm that l amlicenced underprovisions of Chapter9(commencingwim
ro o Section 7000)of Division 3 of qle Rosiness and Professions Code,and my license is in PANELS D
z-�� mu fora and cf�fecJt� —��,r� ,J g J
License Clazs LwA-1 I I UP TO 200 AMPS
Contractor 201-1000 AMPS
ZOyZ ARCHITECTS DE RA MPS
ON OVER 1000 ASQ.FT.FLOOR AREA S/SQ.FT.
OZ-0 1 understand my plans shall be used as public records.
F,,�H L•1 SIGNS ELECTRICAL
¢,ixj Licensed Pro(essinnal
N�o'¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Ni
Q.OiU 1 hereby affirm that I am exempt from the Connector's License Low for the '
F a O y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. p �a
which reforms u permit to construct,alter,improve,demolish,Sr repair any structure1�••!
KWQ2 prior to its issuance.also requires the applicant for such permit to file a signed statement POWER DEVICESg T E R
that he is licensed Pursuant m me provisions of the Continuous License Law(Chapter
p'K.P,4 9(comucaring with Section 7000)of Division 3 ofine Business and Professions Code) SWIMMING POOL ELECTRIC AT UATION
_m Socha[heiaescngnlbcrefmmmndmebaeisformecen thedexempnt to civil Peation of OUTLETS-SWITCHES-Fl%TURES
FZa Sections than by any ve hundred
doll ($50rmit subjats the applicant acivil penalty of
%SO tm1,eown Bofthepeddollarmyem). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPF.CONSTRUCTION
CFo ❑ 1,asownermfineproperty,ormyemployeeswimwagesaztheirsolecompensadon,
s,3°= rill do the work.aodthesbuctureis not intended urofferedforsale(See.9044,Business
and Professions Code:The Contractors License taw does not apply to an owner of
propenywhobuildsorimproves thercon,and whodoessuch work himselfor through his - OCC.GROUP RIiS.UNITS
own employees,provided Ihatsuch improvements are not intended or offered for sale.If,
however,the buildingor improvement is sold within one year ofeamplenioo,the owner- TOTAL:
builder will have the burden of proving that he did not build Sr improve for purpose of
sale.).
❑ I,azownerofthepmpeny,=cxcluxivelycontmctingwimlicensodcono- torsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mneme[the project(Sce.7044,Business and Rofcssimes Code)The Conuncmrs
Licensel,awdoes not applym anownerofproperty who builds or improvesmcrwm,and PERMIT ISSUANCE I
whi.e.e 0,forsuchprojects withacpntractor(a)Iicensed,nurrut the ConhMtols
License Law. ALTER-DRAIN&VF,NT-
WATRR(EA) FEESUMMARY
-
❑ I am exempt unJer Sec B&P C far this reason BACK FLOW PROTECT'.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATIONofoome DECLARATION SCHOOL TAX Y N
' ❑ Ihembyaffiernper,ai inhumimeoruat I have a ficateof ronummm'(Sesure,m as fifievowtC.),hieh Fl%TURPS-PER TRAP RECEIPI'p
Workers Cmploycefonlerthis earacenifiodcopy mercof(Ss,.3gfp,Lab C.)which PARK FEE Y N
/ covers all empinyec's under permit 40 GAS-13A.SYSTEM-I INC,4OUTLETS REq
Policy# BUILDING DIVISION IdiliS
Cor y GAS-EA.SYSTEM-OVER4 EA) PL.ANCHECK FTE
rtified copy is hereby mainland,
Certified copy is filed with the city inspection division. GREASEJINDUSTR6 WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This intermit need antbecomplaed ifine permit is forone hundred do11ars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
to less.)
I ccnifythat is the performance of the work far which this permit is issued,lahol WATER HEATER W7VEN'TP'.LECIB
not employ any person in any m as to become subject to the Worker' lk PAID
z CSmpensationlawsof Califomfa. Date so WATER SYSTEM/IREATING Dae Receipt#
Applicant
z C) NOTICE TO APPLICAN'iIf,after mAing this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. 50.M. TOTAL:
V) become subjwnothe Workers Compenmhon provisions fthe labor Code,you must
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Eli1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7. z I hereby af0ra that thee is a counteraction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) O F.LECfRIC FEE
Lender's Name
C) F- Leraers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
WI certify that 1 have read this aplilismain and state mat the above in6rnatinn is MECHANICAL 171711:corrat.I mgrs,no comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
f' 4' building construction.and hereby u flool represecndvea ofthis city to enter upon the
fA CONSTRUCTION TAX
U z move-me)situ J prvpve,ind msffy and ampkeep has. ALTER OR ADD TO MF.CII.
(We)agree nt save,indemnify and kap harmlus me City of Cupertino against
liabilities,judgments,costs and expenses whirhmay in any way me<rveagaimtsaid City AIR HANDLING UNIT GO IU.000 CFM)
inconsequence of the ranting of this permit
AIR HANDLING UNIT(OVER I).(MIO CFM)
2
SlItivit it Ap cum/Combactor I a EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.000 BTU) Date Racipt#
W ill ma applicant or fomre building occupant store or handle haaadous material HEATING UNIT(OVER 100(100 BTU)
as defined by me Concede.Municipal Code,Chapter 9.12,and me Health and Safety
Code.Section 25532(x)? VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
ISSUANCE DATE
Will thea licanmrfumm buildin none ui rat mrdeviceswhich emit
BOILER-COMP(3HPOR IINI,BW BTU)
hwopp g by the 4 pee n
Districts sir conteminanc as defined by me Bay Area Air Quality Management BOILER-COM11P(OVER IW,BW BTU) r p '
-Distract? /1 D
Cl Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT.
I have read the hazardous rommudsreluiremcnts under Chapter 695 of the JU•tr 21 1993
Cnlifomia Health&Safety Codns e.Sectio25505,25533 and 25534.I understand then /�/a///�/�/
if the building docs nogmm
t conically have a tenam,that it is my resxibility notify the \`
mcupam of the regnerro mm which must be met prior to issuance ofu CWificme of CI I Y Ur l:L. r
Occupancy. IV1' 'YaI
Owneror aulhodaed.gear - Date TOTAL: ISSUED BY: