25973 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINODING-'EIAML I KIUA' PERMIT NO
BUILDING DIVISION .
APPLICATION/PERMIT PLUMBING-MECHANICAL nC973
BUILDING PROJF.CTIDENFIFICATION G J 3
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMOTAL DATE
X173 �' ��D��—• �A�� uNITa LOT» _ '?)
OWNE ;NAME: PHONE: CO OR'S NAME: LIC NO: N/C CONTROLp
/2u� 1,412 rr�► 'i- kv� [ �u wubrt y 9 0
RCHITECFA3NCyI -E LIC NO: A SS: ❑
CONTACT: J,f PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
, PERMIT ISSUANCE � BLDG
ELECT R PLUMB
LICENSED CONR'SD
pyZ Ihercbyufrtthmruntlicensedun&rprovisionso(Chpwr9(cnmecingwith APPLIANCES-RESIDENTIAL s�
F00 PANELS
ECH
C U full force and attar.
ceP/ r • ' ��a.�
QZ W LicenLic.p - UP T0200 AMPS ^�J,�]7••a,
y7y Dale Contractor 201.1000 AMPS
ZOonZ ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.FT.FLOOR AREA $!;Q.FT.
OZ-0 1 undersand my plans shill be used as public remrdr.
p 4 C 1`3 SIGNS ELECTRICAL
gY7K� Licensed Professional
�W OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
SLOaU I hereby Mr.that I am exempt from the Contractor's License Law for the
lal3V-r~ir following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Swhich requires a permit to construct,eller,improve,demolish,or repair any structure
CQ� Prior to its issuance,also require the applicant for such permit to file asigned statement POWER DEVICES
m�'p 0 That he is licensed pursuant on the provisions of the Contractors License Law(Chapter
aqo 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
on 2, oohs'he is exempt therefmmnnd the basis f"t,alleged esemption.Anyviolauon of OVILErS-SWITCHBS-FlXTURFS �'
rya Station]031.5 by any appli.,for a perrait subjects the apPliwhna ecivilprnWyof
CC7 1 l,aom thwnfivebundred proNnyllars.or (yempl NEW RESIDENTIALELECTR _SQ.PT.
m m n❑ I,eeawncroftheproperty.ormycmployeowithwegesastheinole<omPeman., 177 P TO I T CO S'IRULTION
n. will do the work,and the monetarists notmeadedoroffered forsale(See.]034,Buainas
and Pfofessions Code:The Contractors Liana Law does not apply to an owner of
property whobiildsorimpmvesthereon,and who does such workdmseifortlaough his c
employces,providedthat such improvemenueunotintendcdoroffined beside.If, 7 WC, ES. NITS
hawevcr,the buildingor improvemet is sold whJurtm eyeer of templetion,Neowner- T '8
builder will have the burden of proving that he did not build or improve for purpose of E
sE Ic.). TY, PLUMBING PERMIT
❑ Las owner jec,(S e.70 amexdusivel it Predacnions C i0 The ontractons Q E FLOOD ZONE N
<onslmcl the project(See.]OK,Business end Profeniom Code:)The Conuabrs
Licensetrawdoesnmapmysawith ac ofpmperty licensed
dpuouant to the thereon,andTc
PERMITISSUANCE
who contracts forauch projects withncontracroKa)IicensedpwsuanuoThe Cnnmuctors ALTER CA
Liccnu Law. f' ) FEESUMMARY
❑ 1 em exempt under Sa. ,B @ P C for Nis rteson BACK FLOW PROTECT.DEVICE OU1SIDEFEES
SANITARY Y_N_
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT»
• c WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
❑ Ihercby affiant thetihave acmificete ofcutuem to self-insum.oracenifiwm of FlXTURES-PER TRAP �� RECEIPT»
Worken'Compensation losmareeor a certified copy thereof(!a.3gfp,LabCJ which PARK PEE Y_N_
n all employee's under this permit. GAS-E.A.SYSTEMA INC.4 OUTLETS RECEIPT Is
Policy IT BUILDING DIVISIO FEES
COP. GAS-EA.SYSTEM-OVER4(EM PLANCI IECK FEE
ertified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFTCATE OF EXEMPTION FROM WORKERS' GR BASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This seelma-eednm be completed ifthe permit is fortune hundred Miana IS 100) SEWER-SANITARY-STORM EA.20(FT. ENERGY FEE
or less.)
I certify that in the performance of Ne work for which this permit is issued,l shell WATER HEATER W/VENTpiLECTR
ern employ any person in any manner so e ta become subject to the Workeri PAID
O z Compensation laws of Celifomia Data WATER SYSTEMIMEATING Dam Receipt»
Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Cenficate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
rW. to become subject to the Workers Compensation provisions of the L<bm Code,you must
w forthwith comply with such Provisions of This pemdt shill be deemed revoked. BUILDING FEE
WE CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihercby affirm That them is a construction leading agency for the performance of
L) O the work for which this pendt is issued(Sec.309],Civ.C.) ELECTRIC FEE
Lki Lender's Name
C) I e rt
ImJAddress QTY. MECHANICAL PERMIT PEE PLUMBING FEE
I.
Imily.Im that 1 have this application and sesta tial the above information is
astral. Iagra to comply with all city cast county ordi inces and sae laws relating to PERMIT ISSUANCE IE
MECHANICAL E
ybuilding cionsiounctim,and hereby andomizc tepaesenativesofthis city m cmer.,n The CONSTRUCTION TAX
L) Z above-mentioned Property for inspection purposes. TER OR ADD TO MECH.
(we)allose,an save,indemnify and keep harmless the City of Cupertino.,mu
liabilitie,judgmena,costs end expenses which may iranyway ac oeagaih 'said City AIR HANDLING UNIT I]'O 10,WO CFM)
in wnseque� f the renting of this pent
AIR HANDLING UNIT(OVER IO,000 CFM)
7• W1 1W
Signnmm of ApplicwVConaac'or Date EXHAUST HOOD(W/DULT)
PAID
HAZARDOUS MATERI DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receiptp
Will the applicant or future building occupant sem or handle bounden mareriil
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER HX.M BTU)
Code,Section 25532(in?
13 Ycs 13 No NTIELATION PAN(SINGLE RESIU)
BOILER-COMP(3HP OR 100000 BTU) ISSUANCE DATE
wm
Will theapplicantorfurebuilding occupant useequipmcortl<vices which em ,
emit BOILER
hazardous ail comamiounts is defined by the Bay Area Air Quality Management BOILER-COMP(OVER FXLD00 BTU) 1 O
Diamma
❑Y. ❑No NEW RESIDENTIAL MECIi. SQ.IT. �n7,epw
V r
1 have real the fez Cade,materiels reg5,M533a under Chapter understand
of the co)" fns _
ifthepmia Health Ar Safety Code,Sections 25505,2553]and 25534.I undersand @et V IOa,(yS(///���`}�N
if the building does not ly have a sober,Tho it is my responsibility nmify
occupant of the rcyuirementa memn which must be mel prior to issuance of b CartCertificateof ofUr��f
Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE