25501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ....mr"IEMPRRa, PFRNUTNO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDF.NI'IFICA'[ION
BUILIIINGADDRESS: /� SANITARY NO, APPLICATION SUBMITTAL DATE
0 � (— L'�+ - ' NRM LOT is
OW+Nf: S-NAML': D; PHONE: ON'1' CI' R'S NAM - LIC-NO:
4n NIC VVV CONTROLS
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1Ryu TECT/ENGINIiER: LIC NO: AD RE$S: ❑
CONTACT: PHONB: QPY.{ i4 0,'ELECTRIC PERMIT, x -PEE ' BUILDING PERMIT INFO
'+p/y � �'A I SX . bT' BLDG ELECT PLUMB MF.CH
v�7 4 by_:)-1 PERMIT ISSUANCE .�.0 0 ❑ IC{ 1:1 o
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
OCZ I hereby affirm that l sm licensed underprevisionsnfampter9(commencingwith
EddSa9iee11(11it of Division 3nf(he Business and PmfessionsC,e,and my license isin PANELS
FK [VV❑p77�, fall Pone end effect r •Vr/`
< Licc Lic.# - Z 3S L UP TO 200 AMPS
I,<tag Data '� $' Convucmr $ s�-- 201-IOOOAMPS
F-y_Z ARCHITECTS DECLARATION OVER IOW AMPS SQ.IT.FLOOR ARBA $/SQ.FT.
O Z.,N.•O I understand my plans shall be used es public records. r ^psyII
G^ j.4 SIGNS ELECTRICAL u V A L E ® `I 1
Licensed Pmfessionnl t
E WV ast I..-BUILD ER DECLARATION SPECIAL CIRCUIT/MISQ 1 /�
Oy 1 hereby r.ififirm(Se tion 1 um exempt from the Commnors License Law for the �(1 P
4 40y following reason. earl,1.embl.5,Business ed wa,it..fi Code:Any city or county TEMP.METER OR POLE INST. Y YJ 7
h UTEI
which requircnnpermit tocomauct,alter,improve.demolish,an fie a sig mystructure'may prionoitsisxuence,also thea licant❑nsuch nninoRleusineJsre,ement POWER DEVICES
oG�M0 requircs pp pe g TE
yp
,<
pa that he is licensed punuent to the provisions of the Convectors Lic<nu Lew(Chapur
a 1:224 othat be
and the Division Sof lle Business and Professions Code) SWIMMING POOL ELECTRIC A gT10N _
1:2 o, anh:u he is exempnbcrcfrnm and the basis for the alleged esemption.Anyvioletion of ''\\ OUTLETS-SWITCHES-FIXTURE.#
T—Za Section 7031.5 by any npplicantfor a permit subjats the applicant for civil It
of V
not ore than Ove hundred dollen($500).
u�a1 m On ancrnf[hcpr 0p110 armyemployuswithwngesastheirselecompmxetion, NEWRFSIDEMEALELECTIR _SQ, STORIES TYPE CONSTRUCTION
M
Jl do the work,and the strumas isnot intended conflicted for"(Kee.7044,13maress
nJ One
Code:The Contractor's License Lew does not upply to an owner of
property who builds or Improves thereon,and who does such work d mself or through his
wnemployees,proviJulthm such impmvementsvenot intonde proffered forsale.IL OCC.GROUP RES.UNITS
however,the building orimpmvement is sold within one yearofcompledon,the owner.
builder will have the purden of proving That he did not build or improve for purpose of
sale.). 1 '.
❑ I,asownerofthepmpcny,amexclusivelyconuactingwithlicensedconmeimto QPYi•`sn ` PLUMBING PERMIT FEE FLOOD ZONE AIN
construct the inajeo(Sec.9144.Business and Professions CodcJ The Crouran r'a
License Lawdoesnnt opplyto vtowneoofpropeny who builds or improves the.,and PERMIT ISSUANCE
whocentncts forsuch projects with accoutrement)licensed pursued to the Contractors ALTER Law. WATER(EA) .FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE FEE
N
Owner Dote RECFTPT M
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMP EISSATIONDECLARATION SCHOOL TAX YN
❑ Thereby nfrirm,hmlhave ecertificen ofcnnunnosdGinaum,orecertificate of FIXTURES-PER TRAP RECEIPT
Workers'ConpensaJon Ina uraneema cenifred copy therenf(See.3800,Luh C.)which PARK FEE Y_N
coven all employee's under this permit. GAS-EA.SYSTEM-1 WQ40IITLETS RECEIPTS
Policy R BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEF.
❑ Cenlfled copy is hereby fumishe.
❑ Certified copy is filed with the city inspection division. GRF.ASFANDUSTRL WASTE INTIRCEPfOR GRADING FEE.
CERTIFICATE OF EXP.MPT'ION FROM WORKERS' GREASE TRAP SOILS PEE
COMPENSATION INSURANCE
(This section nmd not be complete if Ne Permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in the perfommnce of the work for which This permit is issued,l shall WATER HEATER W/VENOELEGTR
not employ any Tenon in any manner an as to become subject to the WorkersPAID
z Applicant
Compensrtionlawsof Califomia. Dale WA'TER SYSTEMITREATING Date Receipt#
Z Q NOT ICE TO APPLICANT:If.utter making this Certificutoof Exem, h W NEW RESIDENTIAL PLMIL SQ.FT.
p ion,you s use TOI'AI,:
Z
becomes comply,to Ode Worries Compemetiis noisioml beeeIchorwaked. must
!�^ � forthwith comply with such provisions or this permit shallbedcemed mvokW. BUILDING PER
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm thud there is a communion lending agency for the performance of
T7 the work far which this Formi,is issued(See3197,Civ.C.) TOTAL: ELECTRIC FEE
Live Lender's Name .
Lenders Address QTY. MECHANICAL PERMIT:" FEE
PLUMBING IEE
0 V 1 certify[list 1 have rend this application and state that the crave information is
correct.I agree to comply with all city and county ordinances and stare laws relating to PERMIT ISSUANCE MECHANICALFEE
Z,, Thai lding cons[metion,and hereby authorize representatives of this city to enter upon The CONSTRUCfIONTAX
U abovcmetioned property for inspection purposes. ALT ER OR ADD 1'0 MECI I.
(we)agree to save,indemnify end kap hamlets the City of Cupertino against
liabilities,jul,doms,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 1 G."CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
gnmure ul'ApplicanUCommemr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receiptp
Will thenpphent la furore beilding occupm,since an handle hazardous material -
as defined by the Cupertino Municipal Cade,Chapter 9.12,metric Health and Safety HEATING UNIT(OVER 110.000 BIT U) TO" U
Code,Section 25532(v)I
11 Yes 1:1 No VENTILATION FAN(SINGLE REST D) 't",
W itUheupplicanmr fuwrebuildingmcupam useeyuipmemordevic<a which emit
BOILER-COMP(JHP OR 100,000 BTU) ISSUANCE DATE
amadous air mmaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
jlaviaR P A i D
❑Yes ❑No NEW RESIDENTIAL MECB. SQ.FT.
I have=it the hameous materials requirements under Chapter 6.95 of the AUG ex
California Health&Safety Code,Sections 25505,25533 and 25334. 1 undemm�d[hut NY 7199
if the huilding does not currently have a actual,that it is my responsibility to notify the 3
excemant of the requiremems which mux,be me[ our to valiance of a CCnlfi.a of /s
occupuncY. SUED Y L7Pf�PlJrjr/�,r
OwnermamhnrireJ egcm Date TOTAL: ISSUP.D BY: �k(�s��%�[y{#�/