25779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .n1Nr.-nc,nl TRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C (]
BUILDING PROJECT IDEN'FIPICATION L J J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUSUBMITTALgDATE
l V// V'V /> 2 CA) DL UNIT# LOT ^l1VC
fled ':RS NAMEPIfONE: C TRACTOR'S NAME: LIC NO:
-k(, fI zS2 Z 7 z 3 A EL6CX" 6Sy//6 No CONTROL Jr
RCHITECUENGINEER: LIC NO: ADDRESS:f 750 //ZN C t ,[-Z Z
gax rvut A 1s00./ ❑
CONTACT: PHONE:
Yr
�1 /y��a/k QTY. = ELECTRIC PERMIT FEE BUILDING ERMIT INFO
rAll (U` F_0[.. ped��yg'b�G� PERMIT ISSUANCE BLDG ELE PLUMB MECH
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION
0xz Iherebyaffinnued"m licensed underpmvisionsof Chaprer9(commencingwith d �J/
W00 Section 1000).(Division 3 of Ne Business and Professions Cull,and my license is in PANELS T / Aa/'J Y
Cu_ mu force aw errecr. (NS 00 Q Z 0
Fzw License Clgss- - O Lic,# 45W/6 UP TO 200 AMPS
huh Dute 11 Contractor - ' T 201-1000 AMPS '�O /$J iE/C - 9•V "C CsM�O
/�,Z ARCHITE3 SDECLARATION OVER 1000 AMPS SO FT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my pldns shall be used as public records.
t-.to I_-w SIGNS E111MICA1.
Licensed Professional
C T�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xis. I hereby uffrm that 1 am exempt from the Contmctm's Licence Law for the
W 3 n y4 following mown.(Section 1031.5,Business and Professions Code Any city or county TEMP.METER OR POLE[NST.
which requires a permit In ecnstmet,alter,improve,demolish,or repair any swetu.
prior o its issuance also requires the applicant for such Permit to file a signed statement POWER DEVICES
,=<0 that he is licensed pursuant to the provision of the Convectors License Law(Chapter
ec o 9(commencing with Section 1000.(Division 3of1he BusineseandPmfessiors Cale) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt Ncrefrom and the basis for the alleged exemption.Any violationmf
FZ¢
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty.( OUTLETS-SWITCHES-FIXTURES p
�F
nor mom than Eve hundred dollars($500). f OO• G p 0 ❑ I,asownerofthepm NEW RESIDENTIALELECfR _SQ,FT.
o pony.ormycmpl.yeeswiN wagesnthcirsole<ompemalion, STORIES TYPECONSTRUCTION
y3°-° will aothewons Code:
Themreisnot License
Law does not
10 44,owner of
and Professions Code:The Contractors License Lew Jres not apply to rt owner of
property who builds or improves thereon and who sures such work himself m through his
own
ever,tyecs,ping or imovemtsuch enprovemmmsartne earoeampletin.the ower- Z \ OCC GROUP RES.UNITS
however,illhav l the burdenot patent thatsoleiiinoneycat or impmcforn.the f TOTAL: J3,�
builder will have the burdrn mf proving that he did not build or improve for purpose of 'I
ole.).
❑ has the profthepmi(Sec. (1,4,Business
and Prtressions Clicensedcoontracrsm QTY. PLUMBING PERMIT FEE 'I FLOOD ZONE nPN
construct the protect(Sec.oano Business and Professions Cron, The Contractors
License Law d«snot apply ct an owner ofproPeny who builds rs improves thmaron,and
PERMIT ISSUANCE I
who contracts for such projcros wiNa<ontrador(s)licensed pursuant to theCmtrectorx ALTER DRAIN UA
License Law. 1' ) P � UMAIARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT,DEVICE s IDE CS
S Il' YN
,Q/ WORKMAN COMPENSATION DECLA Dole N DRAINS-FhOOR,ROOF,ARIiA,CON.. 5 L % 1 N
l hereby affimr that l have a ceniGcate ofconerrt to self-insure,or a cenificata of FIXTURE$-PER TRAP Fig ,p RECE p
Worken'Compcmaocal Insurance or a rectified copy thcmof(Sec.3800,Lab C.)which A V % RECE N N
Putall.... �.�uylcLNytpTgnit.p3
licya 6�LL XX TT GAS-EA.SYSTEM-I INC 4 OUTUk_ BUILDING.ULUAION FEES
Cum
carries curly,is nanny ramianed.
y GAS-EA.SYSTEM-OVER 4(HA) PLANCHECK PEE
Certified copy is filed with the city mapxfioe division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This Sxtion need not be completed ifthe permit is formic hundred dollars($100) SEWER-SANITARY-STORM EA.2001cT. ENERGY FM
orless.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VEVVELECIR
not employ any person in any mama so n to become subject to the Worker' PAID
z Compensation lows,(Califomh. Date WATER SYSTEM/TREATING
Applicant Date Receipt#
z C, NOTICE TO APPLICANT:If.atter making this Omificate of Esetnpticn,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
(~ C4 become subject to the Workers Compensation provisions of the Labor Code,you must
� ; forthwith comply with such provisions or this permit shall be deemed mvoked. BUILDING FEE
per,• Q CONSTRUCTION LENDING AGENCY SEISMIC FEF.
Z 1 hereby affirm Nat there is a conswetinn lending agency for the performance of
U O the work for which this permit is island(Sec.3101,Civ.C.) TOTAL: ' ELECTRIC ME
Teri Name �N
Ulenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
r DJ 1 ecnify tlud 1 have toad this application and state that Ne above information is
wren.I agree to comply with all city and county eadinanxs and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
I-' buildingconstmctimn,and hereby auNariunimsematives ofthis city to enter upon the
U above-mentioned prpeny l'or inspection purposes. ALTER OR ADD TO MECH. CONSTRULTIONTAX
J111reI
ave indenulify and keep hamdess Ne City of Cupertino agrdonliabiaco anaes,v.whim may in any way accrue againt said city AIR HANDLING UNIT(TO 10,11(1()CFM)
eeBr. ting.!this pemit.
- Zq -Q 2 AIR HANDLING UNIT(OVER NIM CFM)
Signa re fAppl n ornmc r -1 I Date EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATE RIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Rcccipt#
Will the the Cuunt.rfum build ingoccupuntsacmr handle hHealth and Safety
asdefinedhy the32(.)?no icipal Code,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER IW,000 BTU) TOTAL:
Cade,Sxtion 25532(°)? n
11 Yew No VENTILATION FAN(SINGLE RIiSL)
Will this emitanmM, (ding by he .,equip A r Quality
Managemch ent
Di
BOILER-COMP(SHP OR 100,0110 BTU) ISSUANCE.DATE
hazsdous air contaminant defined by the Bay Ane Air Quality Management BOILER 100,WB BTU)
niatdcr? p
❑ n „Yes No NEW RESIDENTIAL MECH. SQ.FT. I� 1D.
I hav read the h rhms materials re,,no ments under Chapter 6,95 of he
Culifomd alth&Sof C ,Sections 25505.25533 and 25534. Iundmstmd Nut 'JAN A �aa��
ifthebuildi drasnm a cntl haveatemnhthatitismyresponsibilirytorimifythe p'{I '2 9
eupnl o s myui ms i<h mu met Prior¢r issunn.c of o Cenificata of
�ee.pa ey (t-Zq-9) CITY �1
Owner or I prized u e Dole TOTAL: ISSUED BY:
OFFIC