25865 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ImILDtNtir-P.LtUrRIM. PERMITNO
APPLICATION/PERMIT PLUMBING-MECHANICAL.
]BUILDINGDIVISION BUILDING PROJECT IDENTIFICATION 25865
BUILDING A]DRESS; olk SANITARY NO. APPLICATIONSUBMTITALDATE
OL UNIT# LOT#
1 IiRSNI"NE1 PHOyE: C NTRACI'OR' Mt:-1-a OSS EIC NO:
NX CONTROL
ARCH1 /BNGINEM: LIC NO
Hn •IL -Rv'
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERM ME
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE TSI
LICENSED CONTRACTOR'S DEAR
CLATION APPLIANCES-RESIDENTIAL L� TOB DESCRIPTION
099 Ihereby affirm that l am licensed undcrpmvisionsofCTapter9(commencing with
1�"00 Section
cill on7nce e"itd of effect. 3 of Ne Business and Professions Code.and my liume is in PANELS r
G VV4,y� License Class c o ,s Lie.# — �� ✓ UP TO 2M AMPS
P 6 a Date LG`' T_L Contractor 201-IM AMPS
ZOy$ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FI'.FLOOR AREA $/SQ.FT.
1 understand my plans shall be used us public records.
RHC SIGNS ELECTRICAL
q�xLicensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
00au 1 hereby affirm that I an exempt form the Contractors License Law for Ne
tt lr-vFi following memo.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE(NST.
CI=0g which requires a permit toconsWct,alter,improve,demolish,or repair myaWCture
s Y� prior to its issuance,also requires the spplimal forsuch Permit to rile saigned statement POWER DEVICES
<p that he is licensed pumumt to the provisions of the Contractor's License Law(Chapter
9(commencin,with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUEor that ION
Sectioheisexempnheref on scam f the bennuafor thealleged flinx,mpfon. civiny l
of OUTLETS-SWITCHES-FIXTURES
�ZQ
Section 7031.5 Man ve hmy undred
lido[ ($50rmit subj«.the epplicanttoacivil penmtyof
Wi t]
no,more than fiv<hundrcd dollvs($500). NEW RFSIDENTIALELECIR _SQ.FT. STORIES ITPECONSTRUC110N
ym n❑ oche wnemnheestoacXor motimenyeeswithwagnasthei(Sm.7ampeviness
will dathewons and e:Tow onturniactot'sLice se La creoes not apply to an weer Of
and Professions CaJa'ITe Contractor's License Law does not apply to on owner of
progeny whohuddsor improves thereon,and who Joessuch work himselfor through his OCC.GRO P RES.UNITS
awnemployees, owidal that such impmvememsarenot(mendedorofferedfarsale.If,
however,the building or improvement is sold within one year of tompletion,the owner
builder will have the burden cd the,he did rot build or improve for se of TOTAL:
porvin6 P purpose
came.} QTY. PLUMBINGPERMITFLOOD ZONE APN
❑ Las the pr eject(Smpedy,em Business
and onnscf g with Beamed Conmtomo
construct the project(Sm.]tk4,Business vnd Professions Cale:)The Canuac[ore
License Lawdcesma.pplyto with ac rawaerty licensed
Punched
uthereon,vnd PERMIT ISSUANCE!
whocomawafnrsuch projects with ecomramnr(n)Iittnsed pursuanua the Contractors ALTER - ER P.
Lieenm Lew. � FF:E SUMMARY
❑ 1 em exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE DE FLFS
NITARY Y N
Owner Dem DRAINS-FLOOR IROOF,A RECF.IPTp
WORKMAN COMPENSATION DECLARATION LT YN
❑ (hereby affirm that l have v certificate ofemrm to self-i........croficareof FIXTURES-PER TRAP RECEIPT#
Workma'Compereation Insurance are anified copy thereuf(Sec.380,Lab C.)which PARK FEE Y N
coven ell employa'a under this permit GAS-EA.SYSTTiM-1 INC.4 OURECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSIT M-OVER 4(EA) PLANCHECK FEL?
❑ Certified copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREASEAhIIUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This rection needno be completed ifthe permit is far one hundred dollars($]M) SEWER-SANITARY-S3'ORM EA,200FP. ENERGY FEE
or less.)
I certify that in the performunof the work for which this permit is issued,l shall WAI ER HEATER W/VBNT/ELECTR
not employ any person in any moaner so as to become subject to Ne Workers PAID
Cnmpematim Lawsaf Califomie. Data WATER SYSTEM/IREATING Date R«sipt#
Q Z Applicant
NOTICE TO APPLICANT:It,after making this Cenifcate of Eacm t n TOTAL:
Z g r o ,you should NEW RESIDENTIAL PI.MB. SQ.PT.
L� V] become object to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit"(be deemed evoked. BUILDING FEE
A CONST RUCTION LENDING AGENCY SEISMIC FEE
a z I hereby nffmn that there is.construction lending agency for the perfomtpnce of TOTAL: ELECTRIC HE
Q «.the walk far which this permit is issued(S 3091,Civ.C.)
Lenders Name
0 U Lender's address QTY. MECHANICALPERMIT FEE PLUMBING IEE
U 1 codify that I have most this application and stere that Ne above infommdon is
correct I agree to comply with all city and county ordinances and store laws miming to PERMIT ISSUANCE: MECHANICAL FEE; -
tiy buildingcuns0uctiun,end herebyamhodre repmaenmtives ofthis city toemerupon the
U above-mentioned property far inspection putpmos. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hamdess the City of C.,muna against
liabilities,judgmems,ort wood su which may in my way aecnevgainsuaid City AIR HANDLING UNITUO 10/00 CFM)
in conupugnap#rf the grentin this�e AIR HANDLING UNIT(OVER 10,1010 CFM)
Measure of Apphemi/Cmaractor L/ Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT('10 110,1100 BTU) Date Receipt is
Will the upplicnm or future building occupant shirt or handle hamrdous material HEATING UNIT(OVER 1 W,W10 BTU) TOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,S«tio❑n 25932(0)1 EINo VENTILATION PAN(SINGLG REBID)
Will theapplictorfumm building«cupvnmumar
equipmedevicea whichemit
BOILER-COMP(31 IF OR la,t00 BTU) ISSUANCE DA E
w
hentdous air contaminants as defined by the Buy Area Ah Quality Management BOILER-COMP(OVER 100,000 BTU) A 9
• District?
❑Yes ❑No NI?W RF.SIDF.NTIAI.MIiCI I. SQ,FT.
I have mm1 the banrdous materials requirements under Chapter 6.95 of the JAN 26 1994
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand Net
if Me Occupant
of the res not quirmsmis ly whicve a h
musttmm,that n is my responsibility bila Certificate
the CI I Y Vr I+LIrCM I IIVV�
O c.pan of the rtquircntcnu which must be met prior w issuance of a Certifrnte of
Occupancy.
Owner orm hmieed.,cut Dam TOTAL: ISSUED BY: �
OFFICE