25982 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILD) -KLEU1 RI A. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 5(] O
BUILDING DIVISION BUILDING PRO]RCTIDENTIFICATION J J o
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMr I�lTAL DATE
L GV t UNIT# LOT# l—�
OWNERS NAME: IU/ N"I- CO NA O 'S AME: t' N/C CONTR`OLYb
AM,< 9 ; 1
WAT� 'DENGINEE ),ICN ; A DRIiSS: ❑
C NTACf: r PITON
G/����� / /q/) 'J��J/l��.{/�� QTY, ELECTRIC PERMIT FEE HUIhDING PERMIT INFO
�Ip�il� [ / 4 /(// PF.RMITISSUANCE BL PLUMB WINCH _
LICENSED CO CfOR'S DECLARATION APPLIANCES-RESIDE L LOB DESCRIPTION
J�dp7`
EMatz Iherehy$,'film lbm I nm liwnsul nnduprnvl$lons ofChnpmr9(commencing wish
00_ Section]0[ of Division 3 ofthr Business and Professions Code,and my license is in PANELS 'T
a,sftL--�I.. full force on defier. UP TO 0. 5
<UA License Class Lic.#
Nati 1l:ne Contramo 201- N
2.Oy3 ARCt11TECT' C IGT OVE 0 SQ.PI'.PhOOR AREA $ISQ.PT.
OZ—G Ad/1-n!]my�lunawhall bra ss �.
Cf_ SIGNS
�¢+ Wy' LI Pro oeslooal
OWNER-B -N Kl,`ARATIO SPE AL IRCUUTMISC.
WyOyU I herehy affirm Ih0 1 am apt from the Convacmrs Licensc Law halite,
FF 3 O ro fyy�� nw all new m.(Section 7031.5,Business and Profession$Code:Any city or county TEMP.METER OR POLE INST.
rya s6hich requires a permit m construct,aper,improve,demolish,or repair any swcmrt
prior m its issuance,also requires the applicant for such permit to rile a signed statement POWER DEVICES
ly_MOz that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
dK�k 9(conunencing wit Seation]000)of Division 3oflhe Business and Prafeuions Code) SWIMMING POOL ELECTRIC /' VALUATION
WM, or that he is exempt therefrom and the basis for the alleged exemption.Any violmionof UTLETS-SWITCIIIS-PIXTURF.S � / l`/ � ��
zQSection 7031.1 by any applicant for a Permit subjects me applicant to a civi l penally of ll`"V/// lY
zzt] nm more lhanfvchun,rr dollars l$SlM]). NEWRESIDPNTIALELEM _SQ.FT.
�' a ❑ Lasownerofteprapeny,ormyemployceswithwagesutheirsolecompensation, STORIES TYPE CONSTRUCTION
L witldothework,and the slmcture is not imm�dednrnffereJ forrle(Sec.](W4,Bus
and Professions Code:'ILe Comranors License haw does not apply Int en owner of
pmpcny whobuildsorimproves mown.and whodoes such work lumselfortluough his
own employees,providedthmsuchimprovements waned ilnendalorofferedforsole.If, OCC.GROUP RES.UNITS
however.the building or iinprovement is sold within one year of completion,the owner T
lambda,will It.,,the burden of proving Thar he did not build or Improve for purpose of
QTY, PLUMBINGPERMIT FEE FLOOD ZONE APN
❑ Lu rofthe
t(Sea. 04, esirarax licensed The
LicenseconstruLaw does
he not(Sea to
owner
oe5send Rofeuions Code:)The Cone".,andractor's PERMIT ISSUANCE
License Laws for nal apply rt an awncrmmacto ny who
sed psoumproves Careegnrd
Lho icense raasforsuch pmjccnwitacontncmr(s)lic<nsW pursuant to Contracmle ALTER License Law. FEE SUMMARY
❑ I amexempl under Sce. ,B&P C for this reason BACK FLOW PROTECT.DEVICE. OUT'TDp`PEES
SANITARY Y N
Owner Date SANITARY
#
UNAINS-PLOOR.NOOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TA% Y N
❑ Iherehy affirm that l have a certificate of conumm�ett-insure,aracenificate Of FIXTURES-PERTRAP RECEIPT'#
Worker,'Gmtpcnsation intimater,or uceniBal ropy thereof(Sea.3800,Lab C.)whichARK S Y_N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4O .E REIVISI #
Policy# r-t BUILDIN RJECTIION ILLS
Company
❑ Cenilled copy Is hereby famished. GAS-EA.SYSTEM-OVERO(li ) LA EF.
❑ Cenified copy is ElcJ with me city inspection division. ORPASIVINDUSTRL WASTP.I CI: R GRA NGf-1
r 4V
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP DATE sFeE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is Jerome hundred dollars 5100) SEWER-SANITARY-ST 'Pw200PT. ENERGY hRF. 7,��d
orleu.)
I certify that in the pweruanu ofine work for which this permit is issued,Ishall WATER HEATER WNENT/ELECTR
nm employ any person in any amour,so as to become subject to the WorkersPAID
Z
Compensation Lawsuf Culifnado Dale WATER SYSTEM/1'REATING Dam Rcccipt#
Applicant
O0 NOTICE TO APPLICANT:If,after making this Cenifasurof Exemption,you should NEW RESIDFNTIAL PLMB. SQ.ET. TOTAL: .� r s
,r 4 became subject o the Worker's Compensation provisions ofthe Labor Calc,you must
4 7 forthwith comply with such provisions or this permit shell be Deemed revoked. BUILDING FEE '41
W r� CONSTRUCTION LENDING AGENCY SEISMIC FEE J $D
5 1 hereby affirm that here is o construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3091,Civ.C.) 'TOTAL: ELECTRIC FEE
I<nder's Name
CU Lenders Address QTY. MECHANICALPERMIT FEE PLUMBING FEL
I certify that I have read this application and state that the above information is
coma.In to comply with all cit and ordinances and stale laws relating to PERMITISSUANCE MSCI IANICAL THE
gree and
he yen county g
U Z athavengamenuniosted hcrebspecti audition representatives m�ves of this nrymrnmr upon the CONSTRUCTION'TAX
U z above-mentioned propcny for inspection ad keepfinalists
purposes. ALTER OR ADD I'O MECH.
(We)agree to save,indemnify and kap harmless the City r Cupertino idCtagainst
in
onsequnce of theanlsand Of expenses eswhichmayinany way accrue against said City AIR HANDLING UN IT(TO IgIN)B CFM)
consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signamreol'Applicant/Contractor Date EXHAUST HOOD(WMUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE IIRATING UNIT(TO 10(1.000 BTU) Dam Receipt It
Will the applicant or future building occupant ware or handle hazardous material
as refined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0011)RTU) L:
Cade,Section 532(e71
Y
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
0
BOILF,R-COMP(311P OR 1 W,0m1 BTU) ISSUANCE DATE
WIII the upplicnm orlumre M1uilAingoccupum useequipmm�tordevlceawhicb ean❑ /g��
harardous air contaminants as defined by to Bay Arca Air Quality Management BOILER-COMP(OVER 100,"BTU) P N
Dixuicl? aY h
Yes ❑No NEW RESIDF,NTIAI.MECH. SQ.FT. Papp [I'
I have read the hve,dous materials reptimments under Chapter 6.95 of the -! Pe . V3
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building Aoes not cumen0y hove atenant.lhm it is my rtsponsibilily le notify the Gqy 99y�
.,,.,art of the requirements which most be,met to,to Issuance of a Cenifieae of �'V.VU
Occupancy. 1-' 1Yi
1 Ownero,authoniredagea Date "Jilt ISSUED BY:
OFFICE