25795 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RICA]' PERMIT NO.
APPLICATION/PERMIT
PLUMBING25795
CAL
BUILDING DIVISION BUILDING PROJFA"f If1N:NTIFICA'1'ION
BUIL DING ADDRIiSS: p� ]]��//// SANITARY NO. APPLICATION SUBMITTALDATE
Li)✓ ;�I(7Ih (f/ UNIT# LOT#
OWNERSNAME: I PITO CONT CTOR'S NAME LIC NO: { —
IJ�� T) ^+ ( r F /. 'y�Y I /N G 1 .J NIC CONTROLk
7.
i•ARCHITECT/L'NGINEL'R: LIC NO: A�;E n� r:pid
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
E P UMB MECH
PERMIT ISSUANCE �
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ej
M=Z I hereby affirm that l am licensed under provlsionsmChapter9(commencing with
xOC Section]000)of Division 3ofthe Buxinbscard Professions Code,and on,license is in PANELS
y+l f fun!race and effect. / l 1, // y"S/[i• L
FZW License Clan Lic.# 6r�4- I G� t IIP TO 200 AMPS
vsQy Date Corrosion /i�;�fy� 201-I00*MI1pS
FyZ ARCHITECTS UECLARAI'ION U" SQ.FT.FLOOR AREA 5/SQ.FT.
Z O,A— 1 undersmnd m I shall he used as blit records. OVER 1000 AMPS
QZ_C ypanss a public
SIGNS ELECTRICAL
Q Y rz j Licensed Professional
Etttt6 OWNER-BUILDER from
the Connector's
on TION SPECIAL CIRCUR/MISC.
XOiU I hereby affirm that 1 am exempt ss an the Conio no o License Isco co the
W 3 m y following reason.erection 7031.5, t,aims and Professions Code:Any city m county TEMP.METER OR POLE(NST.
F which inquires issuance,permit re quires the alter,improve,demolish,merepair sigtiny swment
K=}o prior tohat heir lcensedoomeat also 1.the
tproisionsocant f the ch Cipemtiuo filLicense
La statement POWER DEVICES
m52p that heir licensedpursction7heprovi%vision the CmBusine's License Lawns Coder
n.ao4 9(cnmmencing with Section](IW)of Division Jof the Business and Profusions Code) SWIMMING POOL ELECTRIC www��VALUATION�'1
rx1=m
or he is exempt therefrom and the basis for the alleged exemption.Any violation of EOUTLETS-SWITCHES-FIXTURES V
N.ZaSection 7031.5 by any applicant Join fabontsubjems the applicant to a civil penalty of
S
not more than five hundred dollars($500).q NEW RESIDENTIAL ELECTR SQ.FT.
aim ❑ Luownerofdthe opus mmyemptuded wilhwagesnsthe(Ser.compensation, STOR S TYPE CONSTRUCTION
y3— will clothework.and TheCorcisnot r,Lic, ix,Lorcaw dafm,it apee.]n4n Brooms
ess
and Professions CtNc:'Thc Comranots Liccnsc Law ane.nm apply m an owner of
progeny whobuildsor improves thereon,and whodues such work himselforthmugh his
con employee,,provided Ilem,mch improve memsammaimmraedoroffereefforsale.If, ( C Ip"�, 1y� ARES:UNITS
however.the building or improvement is sold within one year ofcompletion,theowner- 'I IAL/A fl`%7p
builder will have the burden nfproving that he did not build or improve forpurpnse of T 1
sale).
❑ I,awwner of the pmpeny,am cxclusivcly amm�cting with licensed conuactorsto QTY. PLUMBING PERMIT .00 E 1 qPN
nmsvun the project(Sec.]044,Business and Professions Code:)The Continuum's PERMIT ISSUANCE �/�!j/ g
xLaw aacanmapply manawnernrprap nywhanailaxadmpra.xme m.a a DAT
who contracts forsuch projects with a commencers)licenselpsommnuo the Convenors ALTER-DRAIN&VENT-WATER IFA) '- FEE SUMMA
License Law.
❑ I am exempt under Sea .B A.P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR.ROOF,AREA.COND.
WORKMAN COMPEcatemaNDF.CLARATION SCHOOLTAX Y N
�I hereby'Compefirmtomnsura c ma
a come of copy thmm(Sesure,oracenific teofhick RBCEIPI'p
WoJ rs'Compensation Insurance sera cenifie0 copy Nertof(Sec.3BW,Lab CJ which FlXTURFS-P[R TRAP PARK ItiE Y Y
covers all employees and"is permit. RECEIPT#
GAS-EA.SYSTEM-I INCA OUTLETS
Pal cy p BUILDING DIVISION FEES
Company ���' GAS-EA.SYSTEM-OVER4(G) PLANCHECK FEE
❑ Cenificd copy is hereby fumishal.
❑ CcnifiM copy is fled wilt doeciy inspection division. GREASE/UcDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRIP SOILS FEE
COMPENSATION INSURANCE
(This secdonmeednm be camplend ifthe permit is fm one humbseddollms(SIM) SEWER-SANITARY-STORM FA.20(1 ENERGY FEE
or less.)
I certify that in the Performance of the work for which this permit is issued,l shall WATER HEATER WNENT(ELECR
not employ any person in any manner so u to become subject to the Workers' PAID
Compensationlawsof California. Date WATER SYSTEMOTZEVHNG Doc Receipt#
0 z
Applicant
subject NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z NOTICE TO APPLICANT:IL.fm making this Cenificam of Exemption.you should
became,subjeco the Workers Compensation provisions ofthe Labor Cana,you must
forthwith comply with such preem.m minis permit shall be deal revoF.ked. BUILDING FE �w
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE l
I hemby affirm is .I, conswec.3 lending agency for the perfmmanec of
U Q the work for which this permit is issued(Sec.3097.Civ.CJ AL: ELECTRIC FF.F,
Lt. Lenders Name PLUMBING FEF,
F Lender's Address QTY. MECHANICAL PERMIT FEE -
O L) 1 certify that I have read this application and state that the above information is MECHANICAL FEF.
r,'1 W corral Iagree to comply with all city and county ordinance%and state laws relating to PERMIT ISSUANCE
F-'
9L,
building construction,and hereby auninim mpreunwtivea ofthis city menteruponthe CONSTRUCT ION TAX
V Z above-mentioned property for inspection purposes. ALTERORADUTOMECH.
(We)agree to save,indemnify and keep loonln,s the City of Cupertino against
Iiabiliiie,..judgmcros,cnstxundexpenses whichmay in anyway accrue against said City AIR HANDLING UNIT(TO 10,000CFM)
in consequence of the graining of thix .it.
AIR HANDLING UNIT(OVER 10,(1(0 CPM)
Signature of Applicom/Cmince Date EXHAUST HOOD(WNUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazmdous material HEATING UNIT(OVER 100,003 BTU) q'O
as defined by the Cupertino Municipal Code,Chapter 9.12,and doe flcshh and Safety
Code,Section 25532(x)7 VENTILATION FAN(SINGLE RESID)
El Yes ❑No
ISSUANCE DATE
Will theapplicanmrfmaebxildinierV.pamux equipment ordevices whichemit BOILER-COMP(311P OR 100.000 BTU) ^
formulates air contaminants as defined by the Bay Alta Air Quality Management BOILER-COMP(OVER 100,000 BTU) r A D
District?
❑Yes ❑Na NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hae udems materials requirements under Chapter 6.95 of the NOV 22 1993
California health A,Safety Cale,Sections 25505,25533 and 25534. 1 understand that
ifthe building does not currently have a tenant,that it is my responsibility m notify the C''Y
occupant of the u v wwiich must bemet prior to issuance or a Cenifieade of ser LUr-I-tf f f
aeapanc?u - i_<
Owner or tharissd agent x TOl"AL: ISSUED BY:
OFFICE