25609 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO in U;plIl.uURTCA, PERMH'NO.
BUILDING DIVISION APPLICATION/PERMIT PLOMBIi-N G-MECHANICAL ' n C o
BUILDING PROJECT IDENTIFICATION G J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITAI,DATE
2 L� JV��Y�(/� I`�y• UNIT# Lor# 10 3
OWNERS MI?: - PHO F.: CONTRA ' ;L LIC NO:
ARL iI'ILCTIENGINEER: - LIC NO: ADDRFS ❑ '
drx—
CONSH E:
QTY. ELECTRIC PERMIT FI31i BUILDING PERMIT INFO
ELECTPLUMB MF.Cl1
PERMIT ISSUANCE /' ,(G�l{, O ❑_ ❑
I.ICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I berth aflimn that lain licensed under p (commencing JOB DESCRIPTION
C)KZ F old Pr ionanreha ler9(commenoin ih
�i100 Satione,milof Division7of me Business end ProPossions Code,and my licenm is in pANELg
<u� Liken. lass erred.
F7-�W License Class I.ie.k UP T0200A C
m4y Date Contractor 201. AM
ZOyZ ARCHITF.CTSDECIARATION OVE 1 M SQ.FT FLUOR AREA $/SQ.IT.
OZ,o— I understand my plans shall be used as public records. ' .
SIGNS 1ETRI
QyEJ Licensed Professinnd
Sy�< OWNER-BUILDER DECLARATION S CI CUIT/MISC.
0.�dOaF I hereby aflLm mat I am exempt from the Comment's License Law for the
W'3�mfallowing reason.lSection]0315,Rosiness and Professions Code Any city or creamy TEMP.METER OR PO NS .
F
0.1
.] which rcyurn a permit to constmct.aper,improve,demolish,m repair any srrunurt
Ey};. prior to its issuance,also requires the applicant for such permilto file asigned stntemenI POWER DEVICES
00 that he is license!pursuant m the pmvisicmol'the Contractor's License Law(Chapmr
as z 9(com inutin th Seelion 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOLE C
xoLL %wi VALUATION
W=�
car that h0mpriherefromandrr
hazisfm theallegedaxempiioo.Any,violation mf OUTLETS-SWITCH FIXTURES 2/ QA/(x
tZ
Section 7031.5 3L5 by any applicnm torn pemit auhjecte the upplicam nFncivil pcnehy of
Q
not m than five It dollars(S500).
=C NEW RESIDENTIAL ELECTR —SQ.Fr.
mtmyFa ,asownero0heproperty,ormyemplmyecs with wego aztheirsmlecompensatian, STORIESTYPE GQN$TRDL9'[ON
ill dahosivas andthe lm Contratointend..m Law
sal apply AH I,Business
and Professions Code:3Te Contractors License Lew Joe not apply to un owner of
property whohuilds orimprnves themnn.and whodcea such work himselfomhmugh his
however.the
rimer improvement
sold within
iearm dmpletiod the owner. OCC.GROUP RES.UNITS
howeveq the building or of Fmem is sold within one yea of improve for the owner
builder will have the burden o(proving that he did not build or improve for purpose of 1' A '
sale.). TY. PL•:,t"-
❑ Lasowner omhe properly,um exclusively contracting with licensed emaraemrs In Q `1 ,aJ 5/ RMIT FEE PLOODZONE APN
construct the pmjen(See.]044,Business and Proclaims Cole:)The Contractors f »-• . 'J
License Law does not apply tonnownerofyropenY whomildso improves themomand nn
who contracts formch pro,'Leos with ncomnmar(s)licensed pumaom mthe Connector's/ C?'} \fit iV
License Law. e}f,-U_:.J ER-DRAIN&VRN'I'-WATER(PA) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reasod' BACK FLOW PROTECT.DEVICE? OUTSIDEFIlidi
- SANITARY Y_N
'rye Owner Date RECEIPT'#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,R001',AREA,CON SCHOOLTAX Y N
❑ !hereby afBoothetlhaveacenificam of ttmsenun self-inure,Ora cenificam of FIXTURES-Pf:R TRAP RECF.IPI'M
Wmkers'Compensution lnsurnnce oracanilieJ copy thereof(Sec.3HW,Lab C.)which PAR 1ER_ Y N_
covers all employees under his permit GAS-EA.SYSTEM-]INC.4 OWLETS RFCEIT p
Poly# BUILDING DIVISION FEES
Company GAS-EA.SYS'TE YBR4(EA) 1' FI?II
El CenlBW copy is herchy famished.
❑ Canified copy is filed with the city inspection division. GREASEDNDUSTRL WAS CEPTOR GRADING Fig
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP SOILSPFG
COMPENSATION INSURANCE
(This section need not be complemdifthe permit is femme hundreddollara DDR) SEWER-SANITARY-STORM PA.29FfU FEE
or tecta!
I certify that in the pelfonnanceofthe work for which this pemtit is issued,Email WATER((EATER W/VWDELECTR
not employ any person in any manner sa az to become subject to the Workan.'
z Compensationlawaof Culifomia. Data WAT17R SYSIEMG Date Receiptq
Applicant
7O. C) NOTICETO APPLICANT.If.after making this Certificate of Exemption,you ihould NEW RESIDENT! 1. SQ. TOTAL:
Fto beemsembjemm the Workers Cooptrainualeaubior the Labor Code,you mo at
forthwitha ; fowith comply with such provisions or this permit shall be deemed awaked. BUILDING FEE ,
443
CONSTRUC ION LENDING AGENCY C FEE
^a Ihewhyaffirm that there iso construction lendingageacy farthepeffmmanceof
U O the work for which this permit is iuueA(Se.3097,Civ.C.) 1 L: E.ECTRIC FEE .�
Lender's Name
w0 U Lenders Aadma.' QTY. MECI IANICAL PERMIT I.UMBINGFCH
I certify shut 1 have mad this application end atom that the above information is F.0 AL(C1'EH
T 4 co rect. lagreemcomply with .city and counryardinnnase drum laws mlatingm PERMIT ISSUANCE
building construction,and hereby authorize representatives ofthis city menter upon the p IICTION'1'AX
U Z above-mentioned property for insomlion purposes. ALTER OR ADD TO MECH.
(We)some to save,indemnify and kap hamdeelthe City of Cupertino against
l iabilitica,pdgments,costs and expenses which mayim any way azcomagainst said City AIR HANDLING UNIT('1'010,0111 CFM)
nnaoqu Boll mi of roil
` :
AIR HANDLING UNIT(OVER 140100 CFM)
Slgaataw dApplica oatractor Date EXHAUST HOOD(W/DUCT(
rniD
AZARDOUS MKM IS DISCLOSURE HGTING UN11'(TO I W,t]W BTU) Date Rreeipt p
Will theupplicam m future huildingnccupaosmut or handle hazardous maredid HEATING UNIT(OVER 1010,001)11 IT) TOTAL:
as dened fiby the Cupemm,Municipal Code,Chapter 9.12,and the Health told Safety
Code.Section 255326.01
11 Ties 0N VENTILATION PAN(SINGLE RESIDE
Will theapplicantnrfumrebuildingoccupaniuseequipmentordeviceswhichemit
BOILER-COMP(3HP OR I00,0N111 BTU) ISSUANCE DATE
� ?air contaminants as defined by the Bay Ana Air Quality Management
DionelBOILER-COMP(OVER ixid,Brut
Diatrint'1
❑Yea ❑No NEW RESIDENTIAL MI[CH. SQ.FT. P A 9 D
1 face read the hazardous materiels requiremems under Chuptcr 6.95 of the OCTCalifornia Health&Safety Cade,Sections 25505,25533 and 25534.1 understood that C
if the building does not currently have a tenant that it is my responsibilitym notify the
occupant of the requirenmma which must be met prior to issuance of a Cirri ficate of
Occupancy.
�i
Owner(it amhortuJ agent Ilam W A,TOTAL: ISSUED If Y:
OFFI