25648APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUI •. ELECrRICA1•
-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT PIPROJECT'
BUILDINNGGPROJECT
'{:�;b't .p'a• IDENTIFICATION:^•, .}}tiy.;....tp,
PERMIT NO.
25648
BUILDING ADDRESS:
SANITARY NO, APPLICATION SUBMITTAL DATE
Vavu UNIT# LOTH
mal l
iii i '
OWNERS RAME: `/ PIfO'N'E�:/ ` �f
l r si /�11Q%I• TZ��e7�1
!ARCHITELUENGINEER:
CONTRACTOR'S NAME: �� LIC NO: Gam/
%p — 6,5_4
N/C
CONTROL#
LIC NO:
I "A-
ADDRESS:
a7c.GftesTti DA 54au ro5&;7
ONTACf: PHONE:
uw )r�,5 x'. ,. ft rrmv rA at a\ki h two ¢4
« w }r :e:•a :a»3
QTY �° ELECTRIC PERMIT YirP aY 3?FEE'bl
---K11 ,�fR+ P�PIX .
'hP•:a'v n k�BUILDING'PERMIT INF03.9 �. t.:kj`.
BLDG. EL[ PLUMB NIECE)
ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
v aat I am licensed ander lmoomism of Chepmt 9 m
1 hembft w Th (comencing witM1
APPLIANCES - RESIDENTIALOB
DESCRIPTION
Section 7")of Division 3 of the Business and Professions Code, and my license ism
full force and effect.
Date CI _-Z / � Lic. #--Jl SGS
Date /�/ - p�
e��
PANELS #7E%4oip obile,
UPTO n e /
,xT ✓rJ / iO+fiG L
I M MPS
AMPS
I I ARCHITECT'S D
ARCHITECCSDECI.ARATION
I undersand my plans shall be uxd as public ruords.
OVER I
OVER IlgOAMPS
S FT. FLOOR AREA
Q
9SQ. FT.
SIGNS ELECTRICAL
Licensed professional
OWNER -BUILD ER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hertby eR Nat 1 am exempt from the Convectors License law for the
TEMP. METER OR POLE (NST. _ f R p /I
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which tryuiru a pemtil to copswet, aheq improve, demolish, or repair any structure
prior to its isscance,Ns. requires she siMlicant(orsuch permit o file a signed statement
I
POWER DEVICES
that he is licensed pursuant to the provisions of me Contractor's License law (Chapter
9(commendng with Section 7")of Division 3 of the Business and Professions Code)
or that he is exempt Nerefmm and the basis far the alleged exemption. Any violation of
Section 7031.5 by any applicant for a pamtil sciatica the ant pplicato a civil penalty of
SWIMMING POOL ELECTRIC _
. '� ij �l VALUATION
OUTLETS - SWITCHFS FIXTURES
not mote than five hundred dollars (SSW).
compensation,
❑ Lshe wmrond
NEW RESIDENTIAL ELECII�__
RIES
TYPE CONSTRUCTION
Omspeny,ormyemployexwithwagesutheirxle
will dothew'ous andcturre a 0614,Business
immrdese
Consisnot
e: The doessial
La not
and Pmfnsiom Code: The Conlrecto/s License law does not apply to an owner of
property wh.b.ddscoinaproscs daemon, and whodoessuchwork himselfonhrough his
own empim,provided thatsuchimprovera ma mencommaded muttered formic. If.
,
OCC. GROUP
RES. UNITS
however, the building or improvement is sold withinone year of completion, theuwner.
builder will have the burden of proving Nat he did not build or improve for purpose of
QTY'' g PLUMBING PERMIIVia>±I✓' � �+FEEf j
..r1 •M.?LKRFc:I,-..ay.4at. ta:xui'S'15,..t i'-+'ii-a'w%
❑ )I. as owner of she property, amcxclusivel vector NlicensN conlraclast
y contracting
FLOOD ZONE
APN
conswa the project (Sec. 70ol. Business and Professions CNet) The Contractor's
Livens Law' deer not apply, m an owner o' property who bui Ids or improves thereon, and
PERMIT ISSUANCE
Lho icense tow. for such proj«a wiNuconnadorts)licensed pursuant to Contractor's
License law.
ALTER -DRAW&VENT- WATER (EA)
-- °'&A•, as 'FEE SUMMARYi`Y '�R }�
❑ 1 sun exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT DEVICE
OUTSIDE FEES
SANITARY YN
RECEIPT#
Owner Datc
DRAINS - FLOOR ROOF. AREA, COND.
WORKMANCOMPENISATIONDECLARATION
SCHOOLTAX Y N
❑ Thereby affirm mut l have a certificate ofecrsenuoself-imme,oracerificamuf
Workers' Compensation Insurance or a certified copy thereof (Sic. 38M. Lab C.) which
covers all employee's under this petmit.
Policy #
RECEIPT#
FIXTURES -PER TRAP
PARK FEE Y N
RECEIPT M
GAS - EA. SYSTEM.I INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS. EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREASFANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Consisted copy is filed wish she city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER. SANITARY - STORM F.A. 2W17-,
ENERGY FEE
(Dtia xnionneedlum be compined ifthe permit is room, hundred out]. (SIM)
or less)
WATER HEATER WNFNgFlECIR
I certify that isidm pedomanceof inenork far which mispe.is is issued. l shall
no employ any person in any manner neo as to �,_,' y t to he We i
PAID
WATER SYSTENITREATING
Compewu m /G/#7r`/
Date Receipt#
APplicam //��f�Ca/h( '/ppm
^y# �mi; i
NOTICETOAPPLICANT:If,aflomaking this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor CNe, you must
foMwith comply with such pmvixioms .,,his pcmdt shall be deemed revoked.
BURDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Ow them is a commuction lending agency for the performance of
Me work for which this permit is issued (Sec. 3097, Civ. CJ
TOTAL:(
F1F.CRtIC FEE
Lenders Name
vu
QTY f7gf>MECHANICAL PERMITy.s�FEEI
t x , w"lk 3•,.n«e , .>> w s�.9.'
PLUMBING PEE
Lender, Address
I ceras' Nat 1 have mad his apprcati„n and sate that the abn.e information
rrect laFr«trr comply with all city andemumyoMinances and sate laws relminF to
PERMIT ISSUANCE
MECHANICAL FEE
building communion, and hereby aushonze representatives of thiscity no emer.pon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
rep harmless the City of Cupertino against
(We) ape m save, indeV'Rmmi.
liabilities' emcros. cosaa M1icM1 mayinuny wayucerveagainn sa City
AIR HANDLING UNIT (TO 10.(100 CFM)
AIR HANDLING UNIT (OVER IO.ODB CPAP
PAID
canc of the Fr 6
EXHAUST H000 (W/DUCTI
Sign of ApplicanUConmanor
HEATING UNIT (TO IM." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt is
HEATING UNIT (OVEN IW IAB BTU)
TA
Will the applicant or future building occupant store or handle hazardous material
as defined by the Ctipcnioo Municipal Code, Chapar 9.12, and the Health and Safety
VIiNTILATION FAN (SINGLE RESID)
CNe, Section 25532(.)?
❑ Yes ❑ No
ISSUANCE DATE
Will mea licamurfmumbuildin Luxe devfceswbich emit
pp g«cuhe gmpmer
BOILER- COMP(3HPOR IM.000 BTU)
BOILER -COMP (OVER 100,00d) BTIO
hazardous air comaminana m define] by Nc Bey Arta Air Quality Management
Q
I' UISVICII
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
1 have read IM1c hoarduus mmerialx r,quircmena under Chapin fi so ad Ih,
California Safety CNe. 25505. 25533 eN 5534. ( undersand Nat
a
OCT�.1(J!
buildingdoesavc to isnmyresponsibilitytoratify
ifthe buildingd«snot cumns
I S
whave.mnan met of
«rampant of me regmimmema wn;m moa x met poor to issuance or a cemficate of
.
Occupancy.
'tee L�tI , ( ( a if11YV
ISSUED BY:
Owner oraahori,rd agent Dine
TOTAL:
OFFICE