25811 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RDILBIN+.FEEUrRICa PERMITNO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING DIVISION 777 BUILDING PROJECI IDENTIFICATION 25811
BUILDING ADDRPSS:� SANITARYNO. APPLICATION SUBMITTAL DATE
s UNIT# LOT# 1�O�A�
0r-R Pllo coNTIJ�(:J'OR'S LIC NQ - V
Lr %4W IM �. `/.J-1f`dgVr NIC CONTROL#
1RCHITECCTMN INFER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
RBLgO ELEl PLUMB B MI❑l
PERMISSUANCE }UD
LICENSED CONTRACTOR terproSDECLARATION pppL1ANCEg-RESIDENTIAL TOE DESCRIPTION
1400 Ihereby 700H.Ifinnthm l 3 ofth Busised ness ndpr lesions Code,and
mmencive with n G 7� ,wE`�L\VIV
X 00 full o ve dull effect. on J of the Business and professions Code,antl my literal is in PANELS
Licnse Chedeffem.
Q ZVZ,y) License Clara Lic.N IIP T0200 AMPS
yay
Data Conwcmr 201-1000 AMPS
Zl,'z' ARCHITECTS DECLARATION OVER I"AMPS RA VSQ.FT.
OZ'q I understand my plums shut[4 used as public records. #�
'"q 4 k l;crnsed Professional SIGNS ELECTRICAL E R
B�C,t6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. Bw
iW�OaF I hereby affirm that I am exempt from the Contractor's Licenx Taw for the
m "+t following nown.(Section 7031.5,Business add Professions Code:Any city or county TEMP.MCIER OR POLE INST. DATE
l 10 a which requires r permit m construct,alder,improve,demolish,or o pair any.women
Y� priors.its issuance.alsorequimtharloAcamfee such Pruden to ealig titre mens POWER DEVICES
OO that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter
r-4o�' 9(catrtmencing with Section]00F0 of Division 3 ofthe Business and Profeusioru Code) SWIMMING POOL ELECTRIC VALUATI�/y
Ty ZZ Sectioor that 7031. by mpt
reffidand applicant
f to bazisfmthe
cts thedescmpti to Anyviolationof OUTLETS-SWITCHES-FIXTURES �2/nA =w—
F Z G Section]OJ L5 by anY applicant 1'ar a permit subjects the applicant a civil prnelty of — l
�=0 sit more than five hundred dollen FS500). NEW RESIDENTIAL ELECIR —SQ.FT.
�K � PJLPpsowner.rhepmpeny,urmyemployeeswithwegesastheirsolecompevetion, Q STORIES TYPE CONSTRUCTION
a tl�do ffie ork,vW ,,.ctumisnotimmndedomBaedforWe(Sm,7W.Businus
d Profusions Code:The Conwnm'a License Law does not apply to to owner of
progeny whobuildsorimprovesthercon,andwhodoea such work himxlfonhmugh his
ownemployres,providedthat such imprormritsandotinuendedoroffercd Teesside.If, OCC GROUP RES.UNITS
however,the building or impmvcmem is sold within one yearofcampletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I.ms nerofthepmpeny,amexclusivetycontractingwiNlicensedconv wmto QTY. PLUMBING PERMIT FEE FLOODZONE APN
commie,the project(Sec.]044,Business and Professions Code:)The Contractors PERMITISSUANCE
License Law does not apply loan ovenerofpropeny who buildsorimproves thereon.and
who commcn for such projects witha c.ntmc.r(s)licensed pursuant to the Conlrecmrs
License Law. ALTER-DRAIN&VENT-WAT17R(FA) FEE SUMMARY
❑ I am exempt antler Sec. ,B&P C for this rwxn BACK MOW PROTECT.DEVICE OUI SIDE FEES
SANITARY Y N
Owner Date RECEIPTN
DRAINS-FLOOR,ROOF, COND.
WORKMAN COMPENSATIONDEC
LARATLON SCHOOL TAX Y_N
❑ Thereby effimnhetlhave acenificme of conxnno selGinsure,orerertifca.of FIXTURES-PER TRAP RECIi1PTp
Workeri Campenmtion Insurance orattnified copy thereof(Sec.3800.LabCJwhich PARK FEE YN
i covers all employee's under this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT'#
Pal icyN BUILDING DIVISI SITE
Company GAS-HA.SYSTEM-OVER 4(HA) PLANCHF.CK FEIi
❑ Codified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASPIINDUSTRL WASTE INTERCEPTOR GRADING ME
CER'T'IFICATE Oil EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thixscnion need notbe camptemd ifthe permit is formal hundred doilosOt00) SEWER-SANITARY-STORM IA,200FT. ENERGY FLP.
or less.)
I certify thea in the pedmmence of the work for which this permit is issued,l shall WATER HEATER W/VENT/HLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compenssomm Lawsof California. Data WATER SYSHETAGREATING Date Receipt#
Z Applicant
0 NOTICE TO APPLICANT:If,after making this Cmificate of Exemption,you should NEW RESIDENTIAL PIl SQ.Pf. TOTAL:
to become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING HE
z CONSTRUCr1ON LENDING AGENCY SEISMIC FEE
I hercbyaffumthnthereisaconswcuon lendimgegeneyfathelberfommenreof TOTAL: ELF.CI'RIC TLE
U Q the work for which this permit is issued(Sec.309].Civ.CJ
Icret"s Name O PLUMBING FEE F Lenders Address QTY. MECIIANICALPFRMIT PER.
CV 1 certify that I have read this application and state that the above information la MECI IANICAL FF.E
correct.[agree.comply with ell city and canny ordinenera and seam Iles..]air.,to PERMIT ISSUANCE
Vf" building construction,and hereby amhorize representatives ofthis city reenter upon the CONSTRUCTIONTAX
Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and p harmless the City of Cupertino against
liabilities,judgments,costs and lope 'ch meyinany way actor,againclsaid City AIR HANDLING UNIT(TO TO."CFM)
Inc.n. tt of a of t.
AIR HANDLING UNIT(OVER IO,g)(I CFM)
PAID
Si arm r
IficandConlraktor Om, EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIAL DISCLOSURE HEATING UNIT(TO IW,"BTU) Date Receipt#
WiII leapt team nr forum buildin,oecupum store nr handle hezmdoue material HEATING UNIT(OVER IW,OW BTU) T T 1
redefined rylpl I Caperton Municipal Cale.Chapter 9.12.and the Health and Safety
Code,Section 25572(a)P
E)Yes El No VENTILATION FAN(SINGLE RESET) Piss
BOILER-COMP OHP OR I(10,WO ITT U) ISSUANCE DATE
Will the applicant mm
rfure building occupant mosquipmerudeviceswhichemit Ir® W Y
hvardom air consummator as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,060 BTU)
Dlsnim4
❑Yes 11 No 3 No NEW RESIDENTIAL MHCH. SQ.FT. 1993
1 have mrd the corridors mammals requirements under Chapter 6.95 of the
ifteCalifornia Health out radically
Code.yhave..two.that itis my nd 25534,
l ly tonunfy hat
the CITY Uh ti(/rtHI IN(
ethebuildingdoes inearnestlyhaveast The that it my r....toiof ltyenotify the
Ocupam of @e requirements which must he at prior to issuenre of a Certificate of
ccupancy.
Owner or amhorized agent Dore TOTAL: ISSUED BY:
OFFICE