25808 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD 0-ELRCI'RI AL PHRMIT NO.
APPLICATION/PERMIT PING PROJECTMECHANICALiPICA 2 5 8 0 8
BUILDING DIVISION - BUILDING PROJECT IDENTIFICATION L J O O
BUILDING ADDRESS: SANITARY NO. APPLICA'I ION SUBMIITALDATE
XO 12'1A/ �E1_1_ UNIT# LOT# 1
OWNERS NAME: PHONE: �157-73'71 CONTRA OR'SNAME: LICNO:
OF M. Cl ✓k NC CONIKOLN
•A RCHII'EC'17ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDEG ELECT PLUMP
PERMIT ISSUANCELICIIhI 'IYyl�\1��gg��
ratedI been TRnderpmSDECLARAT[ON APPLIANCES-RF.SIDP-NTIAL )OB ll�unnrr..�
000 thereby off nn thorium licensrAunderpmvisions of LTepmr9(commencing wish
�i100 SectimmeandofDivirion]of the Business and lTofessiorrs Cale.anJ my licenu it in ppNF.IS
y full force enA effect.
Gz� Licenx Cless Lic.M UPTO200AMPS f
y G
Moe Date Contmemr 201-1000 AMPS
ZONZ, ARC]I ITF,CT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $fSQ IT"
0Z_9] luntlersmnd mnsy pla .hell he uud es public records.
r ',^ 1{
$y Licensed Professional SIGNS ELECTRICAL. S �/ ..
OWNI;R-BUILDER DECLARATION SPECIAL CIRCU117MISC.
kOyF I hereby affirm that 1 am exempt from the Contractor's License Law for the
W3a,� followingrcnun.(Section 70315,Bardiessnnd Profession,Code:Any city.,county TEMP.MEI ER OR POLH INST.
I_ 0�5 which requires a permit to construct,alter,improve,demolish,or repair any structure
Inn priormiui...unce,Ms.requirextheapplicant I.r such permit 1.file.signedstatemem POWIIR DEVICES
ce tY 0O that he is licensed pursuant to the pravisiovs.f the Contractors Licenx Low(C mdr,
dy m 9(c.mmene' tb gecti.nJ(go)of Division]ofthe Business and Profession Cude SWIMMING POOL ELECTRIC
xoLL mg wi I VA UATION
Ed
or that he is exempt therefrom and the basis for the alleged exemption.Any violationof GUTLurs-SWITCHFS.FIXTURES f�
GSection 7031.5 by any applicant for a perm,stijects the vpplicnm macivilpenahyof o 2. 8 1 �
0 more than fva hundred I llaa($500). NHWRESIDENTIALFLIiCTR S .FI'. r IIJJ _
,nsowwroDhepropeny,ormy employees with wages as their sole compensation, Q SjO iS TYP�( fN ON
y3. illd.me wnrk.and the strvctumisnotimendMon,(fared forsae(Sa.7044,Businev ///�\1
d Professions Cale:The Contractors Limroe law does am apply t.an owner of
pmnywhabuildsorimpmvexthereon,endwhodmssuchworkhimselforthroughhis
empinyeesilding r improvement
zuement iovememxareneyearMemanpi fared foe sme.l6 ) ^ NI'T'S
a
However.the building orlmprovenmmia sold within oneyear.fn,mplgi.n,the owner- T g.
builder will have the burden of proving that he did not build or improve for purpose of /
val
0
❑ I,asownerofthepropeny,amexclusively, contracting with licensed convactorsm QTY. PLUMBING PERMIT F-E APN
.sumer the project(Sec.7044,Business and Professions Calc:)The Contractor',
License Lnw docs not apply man ownerofpropeny who builds orimproves[hereon,arta PERMIT ISSUANCE
who contracts for such pmlcets with acommea r(s)licensed pursuant o the Commea r',
License Law. ALTER-DRAIN&VENT-WATUR(EA) FEE SUMMARY
❑ 1 ton exempt under Site. ,B&P C for this rcaum BACK FLOW PROTECT.DEVICE
OUTSIDF, MS
SANITARY Y_N_
Owner Dau GRAINS-FLOORROOFAREAGONDRECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ Iherehyuffrm that l have a certificate ofconscnt to self-insm,aracenificvm at FIXTURES- RECEIVI'p
Workers'C.m py PER TRAP
pensvtlonlnsumnaoreceni0edw therwf(Sec.7go0,Lab CJwhich PARK HE. YN
covers all employees under this permit. GAS-R1.SYSTEM.LINC.4 OUTLET'S RECEIPT#
Policy 4 BUILDING DIVIS ON FEFS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifed copy is hereby fumished.
❑ Cenifed copy is filed with the city inspection division. GRHASEpNDUSTRU WASTE INTHRCEITOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKIiRS' GREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This section assal of be completed ifthe permit is for one hundred dollars($100) SHWER-SANITARY-STORM FA.200mT. UNERGY FEE
or less.)
I certify that in the perfmmaoce of the work for which this permit is issued.I shall WATER I ITATER WNENT/ELECI'R
not employ airy person in any mature,or as m become subject to the WorkersPAID
z Compensmion Lowsof Califomia. Date WATER SYSTEM/1'RBAIING Dam Receipt#
Applicant
z 0 NOTICE TO APPLICAM`.If.after making this Certificate of Exemption,you should NEW RFSIDEM'IAL PLMB. SQ.FT. TOTAL:
HV) become Subject to the Worker's Compensation provisions of the Labor Cale,you must
1 forthwith comply with such provisions or this permit slor be deemed revoked. BUI LDING FEE
aQ CONSTRUCTION LENDING AGENCYSIe1SMICFT.E O
5 z I hereby affirm that then is a construction lending agency for the perfornunce of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(See.7097,Civ.CJ
Lender's Name 14
OU Leadera Address QTY.' , MECI IANICAL PERMIT FEE�F PLUMBING FEE
L certify that I have.,,it this application and slaw that the shove information is
t�" a correct. Ingree to comply with all city and county oNinancee and stmelnws relntingm PERMITISSUANCE MHCIIANICALFEE �w
rA building construction,and hereby autherrempuxenmtives ofthis city to enter upon the CONSTRUCTION TAX
U Z above-mentioned proect
property for inspection Impasses. ALTER OR ADD TO MECII.
(We)qpm .1 mnify and keep harmless the City of Cupertino ageimt
liabilities,' noms,cost nJ aspens hich may in any wayvccrva egeinstanid City AIR HANDLING UNIT(TO 10,00)CFM)
it u nr the ming ofthi,
it.
_ AIR IfANDLING UNIT(OVER I O,ON)CFM)
Signal Ctorr Dau E%1 IAUST HOOD(W/DUCD PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
ill the appiicanmr future building occupant store or handle hazardous material IIIiATING UNIT(OVI?N IIXI,T]W BTU
na defined by rim Carom..Munieipul Cade,Chapter 9.12,and the Health and Safe, )
Code,Section 25532(a)9 VHNTILATION FAN(SINGLE RRSID)
11Yes 13 No
BOILER-COMP(3HP OR 100,00)BTU) ISSUANCE DATE
himoWill the uconcninants re defirn by
nBay equipmentQualit Management
Rf p P D
Domdous vii contaminants m Jefned by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU) Y' W
District!
❑Yes ❑No NEW RFSIDFNTIAI.MECIi. SQ.FT. ]�
1 have read the const dens materials mquiuments under Cnnpter 6.95 of the {/ 7,93
California Heath&Safety Code,Sections 25505,25533 and 25534. 1 understand mm /s' 7
if the building does not curren0y have a tenant,that it is my responsibility to notify the V Vf VULCf-I
cupant.1'mo requirements which must be and prior m Iseuuoeu of o Certifeme of I I/�
Occupancy.
Owner or aufloired agent Dam I(T ISSUIID BY:
OFFICE