16869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'Fmk'+:-RI'RCTR PEaMITND'
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MRCHANICAI. tea ^
BI111.11IN0 PRIId C(T IIIEN'TIFICATION {V� }V(
BUILDING ADDRESS: SANITARY NO. APPLICATION SUOMI'I-I'AL DATE
�f7 d�,Cue--s � 40t
UNITM LO"fp
W SNAME: PHONE: CO RACI'OR'SNAME: LIC NO: N/C CON TROLp
3
CIII :CTGINEER: LICNO: AD ESS: ❑
:ONTACI': PHONE: L A r}.; C ct .I6Wi e` -
QTY.; Ell
- . FEE. - `' BUILDING PERMIT INTO
Q'S b 'SAF.t- R 'K' BLDG ELECT PLUMB MI?CH
PERMIT ISSUANCE (D O ® AT fa
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL 12f KV
Qtyz I hereby off rat that lam licenmA underprdvisions of Chupter9(commrncing with JOB DESCRIPTION
Iu00 Section7000)df Division 3olthe Basinesspo/d�d P�rofAessiimas Code,and no,license is in PANELS
Fqz� force effect
LInN wl'M"]9�L d UPT02MAMPS
6�rn<m Contractor 201-1000 AMPS
`L FOy^ HITECCS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA
OZ—Q lundersmnd y plans shall bei used as public records. GC/
f-,rn,FeW SIGNS FT ECfRICAl O6 10�
Q 2, LicensulProfessionel �06z
KW V OWNER-BUILDER DECLARATION the CATION SPECIAL CIRCUIT/MISC. �J l.)
0 WO¢ I hereby off Ihm I wn exempt from the Contractors License Lew for the ��/ /
'10. following reason.(Section]031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. Z 6/v
m.J which requires a permit to construct,alter,improve,demolish,or repair any structure
W}:� prlorto its issuance,also reclaims the applicant Gorsuch permit tofleasignedstalement POWER DEVICES
that he is licensed Purolator o the provisions of the Communes License law(Chapter
Lyo�' 1)(cmmmencidg with Section VadOdf Diluom.3 of the Bminalited Profssmion Coda) SWIMMING POOL ELECTRIC VALUATION
yXf_w or that lie is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%TURES
QSection 7031.5 by any applicant for apmorit subjects the applicant a civil Penalty of
Q
t mors than Bve hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ.
yrFo ❑ I,asowncrofthepropeny,ormyempluyaswithwagnnlheirsolecompensation, STORIES TYPI?CONSTRUC[ON
y,3m will do the work,and the structumis not deadmoreffered for sale(Sec.7N4,Business
and Professions Code:The Comucmes License Law does not apply to an owner of s —
peo,m y who huilds or improves thereon,and who does such work himselfor through his
own employees,provided that such improvements rommu mendedoroffered percale.If, Lit,I OCC.GROUP RES.UNITS
however,Ne building or improvement is sold within one yearofCompletion,theownce- TOTAL:
builder will have the burden of proving that he did not build or improve for par mae of
a❑)IasownerofthepmNny.amexclusivelycontrwtingwiNlicensWcontramo to QTY. ai PLUMBINGPERMIT FEE FLOODZONH APN Z
construct the pmjmt(Sm.7044,Business and ProfessionsCoJe:)The Commctur'e PERMIT ISSUANCE. �� 00
License Lawdoes not applyto an ownerofampery who buildsorimprovm thereon.and
who emntredta for such projects with a commmor(s)licensed pursuant to the Contractors AL'fBR-DRAIN&VCN'C-WATER(FIAT License law. FEE SUMMARY
❑ 1 not exempt under Sec. ,B&P C for this reasonBACK PLOW PROTECT.DEVICE OUTSIDE r S
SANITARY Y_N
Owner Pam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPI'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercby affum thotlhavc oc<rtifcam of mnunno self-ins ,ora anifilderd R13CP.IPIk
Workerx'ComlNnsationlnsuranceoracenifiedcopylherc .38110,Lab C.)which FIXTURES-PER TRAP PARK PEE Y N
coven all employee's under Ibis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Policy M BUILDING DIVISION FEIS
Company AS-EA.SYSTI?M-OVIZR4(1?A) PLANCIIECK FEE .ZQ-(1
❑ Ce dfied copy is hereby f ished. (�¢
1:1Cedifiedcopyisfledwi theciryma,socdondivisio SE4NDUSTRLWASTEINTERCEPTOR GRADING FEE
CI?RTIIECA MO EXEM CL ORKERS' GREASE.TRAP SOILS PCE s V[J
(Thissectionnced mol becompl edif e l isforonehundreddellar(S� SEWER-SANITARY-STORM EA.2lgFf.
or less.) / E �`OO
I cmify that in The. mf woe ,which this permi sued,lshall WATER HEATER WNENLPLECI'R �_ r—" g{, w
not employ any Feel in any manner n to become su to the Wm=1' Alp aXiy2
z Compensation laws of Celifomie. Dam WATER SYSTENUTRF.ATING Woo Rdceipta
Applicant
00 0. NO'DCE TO APPLICANT:If,after making this crtificatc of Exemptidn,youshuuld NEW REST DENTIAL PLMB. SQ.FT. TOTAL: 0�
fA becomesubject subjeco the Worker's Compensation provision of Nlabor Carl laCoda you must
7 forosith comply with such provisions or this permit shall he deemed mvokW. — /G 4 BUILDING ME. 2 —a
Q CONSTRUCTION LENDING AGENCY LHI=RIC
E d
1 hereby affirm that them is a construction lending agency for the performance of V
V O the work for which this permit is issued(Sm.309,Civ,C.) TOTAL: 00. FEE Zloader's Namc ��UFF I<nder'a Address QTY; MECHANICAL MiRMI'I'"` - 'r FEE FEE 2'1V 1 anify that 1 have madthis appfcatioa and mite that the above information is t 7cored, la zee ld cam I thell cit dcoum Ninunas end smm lows rclutin m PERMIT ISSUANCE -O� AL FEEg Py wi yw yn gbuildingeonstructidn,add hereby nothern mprunmdvn ofthis city m enter upon theV above"mentagree propertyfnrmnify and purposes. ALILR OR ADD TO MECH. TIONTAX
(We)agree nt save,indemnify se.kap harnlns the City r Cupertino against
liubilities.judgmenm,costsandexpenuswhich may inany way acerae against said(7iry AIR HANDLING UNIT(TO 10.000 CFM)
in n,Yuen the mall of thix permit.
,0 AIN HANDLING UNIT(OVER 10.000 CFM)
SOrmumeo pFiat/C n actor Dam EXHAUSTHOOD(W/DUCT)
PAID
IIAZAR[ US MATERIALS DISCLOSURE HEATING UNIT(TO IOg000 BTU) Date Receipt N
Will the applicant or future building document store or handle hazardous material HEATING UNIT(OVER IOO,IXIO BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Sol
Code.Sammy 25532nd?
11 Yes ❑No VFMILATION FAN(SIN(SINGLERLSID)
t.
Will air co icantmfuwrebefned by thentuse equipmentauality Management
BOILP.R-COME DUE OR 1011.000 BTU) ISSUANCE DATE
r
buaonldus slr mnmminems os defined by the Buy Area Air Quality Management 1 651
Dislriu'1 BOILER-COMP(OVER 1(q,IMU BTU)
❑Yes ❑No NEW RFSIDEW AL MECH.—SQ.FE OCT - 3 199
1 have mad the hu
ordo is materials requirements under Chapter 6.95 of the
Culifdmia Ill&Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if the building it.dm currently haveammnm.that it is on,neponsibilitym unify theCITY yr wr ,iti- t
occupant of the requirements which must be met prior m issuance of a Certificate of
�;Oc'sdpancy.
Owner nr aullamiud agent Dam TOTAL. d�w 14 1 ISSUED BY: