25617 I APPLICANT TO FILL IN•INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHANICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
25617
=BUILDING PROJEOT,11IFNI'DICATION'--
BUILDING ADDRESS: /� SANITARY NO. APPLICATION SUBMITTAL DATE
(tr.rTE,, Uric - UNIT# LOT
OWNERS NAME: HONE: CONTRACT'OR'S NAME: IAC NO: _NICT CONTROL#
J G
•ARCHGfiCT/ENGINEER: LICNO: ADDRESS
CONTACT: PHONE: 4'-0,'sy < em" '3.` `d i b F? P, ,�E- z z ,.F'q r` '
QTY. ELEGTRICJPERMITety' �aBU1LDIN0 PERMIT:INFO
Fg ffi'. .z ('° BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE ❑ ��gz,-.pp�/y(�/ItA El
LICENSED CONTRACTOR'SDECLARATION PANELS CT3S-RESIDENTIAL U M — PPION
OCZ Ihemby effort that Iof Division
3 ofth Bused undue and
Professions
Chapter and(commencingsewith
ti100 Section 70bad
ce and effect. on 3 of the Business and Professions Code.and my license is in PANELS
F ❑
full ic License
Cladeffect. UP TO 200 AMPS L
FZ� License Cl ass Cour
m 6 y Dam Con[racmr 201-1000 AMPS' S FT.FLOOR AREA $/SQ.FT.
Z8y7 ARCHITECT'S DECLARATION OVER I""I's
Q
OZ^G Imumbiand my,l.r,hsll be used aspublic records.
r„ ,Fpul SIGNS ELECTRICAL
gillgillLicensed Professional
OWNER-BUILDERDECLARATIONConti ON SPECIAL CIRCUIT/MISC.
yyO4U I hereby affirm That 1 am exempt from the Contrn sCo License Law for the
ix 3 o vFi following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. C
[�„�O which requires a permit m construct,site,improve,demolish,or repair any structure R
�N`° POWER DEVICES - ■
}� thionei licensed se, to the
tprovisions
r visio softhe Co Brute's License
La s(Chapter
iy�dO 9(comthat he isncing with Section
7000)of Division
3 of the Business and Preenions ode)
❑y. SWIMMMG POOL ELECTRIC
d e 9(wmmeisixemitherefroiandthebisision3oflheedexemptio.An, iolaCode) DATE ION
M, Smithat 7sexempan,applicant
far
basis subjeelkgWexempdon. civil
of OUTLETS-SWITCHES-FIXTURES
Section 7013 LS by any applicam farapennit subjects the applicanneedvll penalty of
C, -
rn more than Eve hundred&[[.,a($500).
- NEW RESIDENTIAL ELECTR _SQ.PT. STORIES TYPE CONSTRUCTION
n❑ the
work,mubepropeny, isnotapended croferegesasthei(Sole compensator,
a will dethewons Code
The Cureianoo,License
Law
do s not apply 0094,owner of
es
and Professions Cnde:The Conlmemr's License how dres not apply ro an owner of
property whobuiIds or improves lhereca and whodoes such workhimselforthroughhis
own employers,lding rimprasideat suchimpmaemeithin nsine earcW completioffirmadon.
formthen nIf,
OCC.GROUP RES.UNITS
however,the building burden
of moving
is said within one year of completion,purpose of TOTAL:
builder will have the burden of Prov ng that he not build or improve for purpose of
sale). 'a s g y 'fa$k xo
❑ 1,m;ownendthe en QTY A ay PI UMBING PERMIT-s*a sx x•FEE'- ' FLOOD ZONE APN
prop y,am exdusrvelycomrading with licensed contractors l,__I• - ,)'Z_ ,111 x x x l I k=
comfort the project(Sec.7044,Business and Professions Code,The umoomtu'S n a
License Law doesnotapply roan ownerofproperty whobudd,mimprovesthereon,end PERMIT ISSUANCE
who cnmractsforsuch pmjurs with a comments)licensed pursuantothe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) �,xa T i
FE
-' B SUMMARY
❑ l am exempt under Sec. .B ffi P C for this reason BACK FLOW PROTECT,DEVICE O TSIDE FF..S
SANITARY Y' N
Owner Date• DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#oo WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Elffi
I hereby arm that l have acenificateofconsent toself-insure,eracenificateof FIXTURES-PER TRAP RECEIPT'#
Workers'Compensatien Insurance at acertified copy thereof(Sec.3800.Lab C.)which PARK FEE Y N
ars all employee's under mis permit, GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Cenired copy is hereby famished. -
❑ Cedifed copy is Filed with the city inspcc[ion division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbscompleted ifthe permit is furnehund(eddrllars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
Isorrily that in the performance of the work for which this permit is issued.I shall WAIF. TER W/VENT/ELECTR
not employ any person in any manner ao as to become subject to the Workers' PAID
Compensation Laws of California. Date ATER SYS .M/IRFATING Date Receipt#
0 Z Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should ESIDleWIAL PLMB. SQ.FT. TOTAL:
T/0 buomesubjecfto the Worker's Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
�i
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembynffirm[hot there is s cormaction lendingagency for the performarrusecd
zt
U O the work for which this peon is issued(Sec 3097.Civ.C) T ELECTRIC PEG
Lender s Name S.6 Fx 5 5 a
1 i #+9 PLUMBING FEE
u” Under s Address QTY, a�' MECHANICAI:PCRMIT ,,y PGE .;
U I sanity that I have teed thin application and state that the above information is +x '
W correct. f agree to comply with all city and county ordinances and state laws rolatingm PERMIT ISSUANCE MECHANICAL PEE
building combustion,and hereby authorize representatives ofthis city to enter upon the
CONSTRUCTION TAX
U z
above-mentionedrom pmprnyfor inspection purposes. ALTER OR ADD TO MECH.(Wc)agree I.save,indemnify and kap humins the CityCoCupertinoagainst
liabilities,judgments,cows and expns
eeswhan
ich may in y way accrue against said City AIR HANDLING UNIT(!010,000 CFIH)
in�wr f the�g,tranting ofthisppermit.
ll. 't ,K6, �'�I A`q3 AIR HANDLING UNIT(OVER IU,OIXI CFM)
Signature of�cartt/'IContracmr Date 1?)(HAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt It
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 DTD) TOT
as defined by the Comedian Municipal Cade,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(x)0
11 Yes El No VENTILATION CAN(SINGLE RESID)
BOILER-COME(311P OR 100,000 BTU) �SU�INI DATE
- Will thenpmliwm orfuturebulldingeccrpant ueaequipmenmrdeviceswhieh emit D '
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BI U)
District?
ocr -8
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.FT. ����
1 have read the harandous materials requirements under Chapter 6.95 of the - + T /`
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undershoot that QTY 1Tz V OF CI PEH I IN 7
T the building does nor currently have a tenant,tort it is my responsibility m notify the r
occupant of the requirements which must be met prior to issuance of a Certificate of
cy
Occupan .
Owner or amhorized ahem Data TOTAL: ISSUED BY:
OFFICE