25010 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMIT NO. 25010
CITY OF CUPERTINO PLUMBING-MECHANICAL
BUILDING DlvisloN APPLICATION/PERMIT nuaowr oxo E T nxnrlRlcATum
BUILDINGADDRESS: 7 SANITARY NO. APPLICATION SUBMITTAL DATE
6 UNIT# LOT# l.Q'
OWNERj NAME r PHONE: CONTRACT'OR'S NAME: LIC NO: NIC CONTROL IfRCIII'I'EC tr
GINEER: LIC NO: ADDRESS:
CONTACT: PHONE: QTY, E4ECTRIGPERMIT' -,FEE- - -BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE F-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
POO Ihereby ammvision amlicensed Business tovisionsofCh.pmr9(it mmecensewith
tt100 Sermon 70P0)af Division3 of the Business and Professions Code,antl my license is in PANELS
[- full force and of cL pp ase 97S �
6zu Licene C=ass '�3 .�4p.# UP TO 2BOAMPS 1\ r✓lYA/ 'e
y Q a Daie Commcmr 201-I000 AMPS SQ.PT.FLOOR AREA 8/SQ.IT.
z0an, ARCHITECTS DECLARATION OVER[ON)AMPS
O ar ar O I understand any plans shall be used as public menrds.
14 F; SIGNS ELECTRICAL I I v+t L E ® '
� Licensed Professional
mm OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. p
�OyU I hereby affirm that I am exempt from the Cnntmators License Law for the u— U ,E..({
3 0.h following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
at, which requires a peirnit m constmct,alter,improve,demolish.nr repan any svunmre41
�WQ� polo,it,issuance,ad. thea licant for such Dp file a sined statement POWER DEVICES DATE
requires pP Penni 6
W rL G p that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
a o�' 9(commencingwl0i Section])00)of Division 3 offer Business said Professions Code) VALUATIO
or onhm lie is exempftherefrom and the basis for the alleged exemption.Anyviolmlon of OUTLETS-SWIi'CHF.S-FI%TURES
QY Section 7031.5 by any eppfeantfor.Permit subjects the applicant to a civil penalty of not more then five hundred dollars($500).
NEW RPSIDENTIALELECTR —SQ,Pr.
W ❑ I,asowneroftheproprty,ormyemployeeswithwagesastheirsolecompensatioo, STORIES TYPE CONSTRUCTION
p• wllldo the work,andthe structureis not Intended proffered forsale(Seu 7044,Business
and Professions Code:The Contractor's License Law does not apply In an owner of
propertywhobuildsorimprovesthereon,andwbodoessuch work himselforthroughhis OCC. EAPN
own em ployeos,provided that s uch improv emems aro not Inlended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale) QTY, 'PLUMBING PERMIT ° t ".FEE
❑ I,as owneroftheproperty,run exclusively contracting with licensed contractorstn - FLOOD ZONE
License
at the project(Seo.to an
Business and Pwhol adf Cade:)The Contractor's PERMIT ISSUANCE
License Lawdoesnotapplymnn ownuofpropety whobuildsorimproves thereon,and ..S�
wlmcpmrmts for such projects with.coawmoica)licensed pucsuannothe Contractor's ALTER-DRAIN&VENT-WATEREA '
License Lam.
( ) - , - FEB SUMMARY^ ^ -
❑ I nm exenrpl unJer Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OIITSIDP.FEES
SANITARY Y N
Owner Data DRAINS.PLOORROOFAREA, RECEIVI'#
, , ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that l have o cenificam ofecaranfto self-insure,ora cenificateaforFIXTURES-PF.R TRAP RECEIPT#
keri Compensation Insurance or aceAfietl copy thoomf(Sec.3800.Laid C.)which PARK FEE Y N
RECEIPT is
,scientific I t '^p it. _�., OAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Policy#
Company P
Certified copy gis heroby`famished.GE GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑
Certified copy is fled with the city inspection division. GREASB/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tliissection neednolaciumileted ifthe permit is Tomas hundred delta,($1W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
po)es'.)
I c rflfy that in the performance of the Work for which this permit is island,)shallWATER HEATER W/VENT/ELGCTR
not employ any Person in any manner so as to become subject to the Workers' T PAID
Compensation Laws of California. Da¢ WATER SYSTL IRBFUND Dale Receipt#
O Z Applicant
0 NOT ICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIC SQ.FT. TOTAL:
V) become subject the Worker's Compensation provisions of the Labor Code,you must
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aA CONSTRUCTION LENDING AGENCY SEISMIC FEB
UZ 1 hereby affirm that there is a construction lending agency for the performance of �T s ELECTRIC PEE
O the work for which this permit Is issued(Sec.3097,Civ.C.) TOTAL: 2•
Lenders NamePLUMBING FEE
0 H Landers Address QTY -), . „MECI{ANICAL REI MTT6 a a x'FEE'-' ,)
U 1 cenify that I have lead this application end sort.marine above informations
correct.I agree to comply with all city and county ordinances and smm laws relating to PERMIT ISSUANCE ME,CHANICALFEB
V Z building construction,and hereby momfiizerepresentatives ofthis city to enter upon the CONSTRUCTION TAX
above-mentioned property for inspection peeps. ALTER OR ADD TO MSCIL
(We)agree m save,indemnify and keep harmless the City of Capetian against
Iiahilldes,judgments,costs and expenses which may in any way acmueagainst said City AIR HANDLING UNIT(TO FLOW CFM)
nseyuence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
name of Applicaal/Commcmr Date EXHAUST HOOD(W/DUCT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) one Receipt# ^1�
Will the applicam of future buildingNou,scntsme or handle hazardous..,,do[ HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupotin,Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RP.SID)
❑Yes ❑No
ISSUANCE DATE
Will theapPliranmrfumrohulidingoecupanmseequipmentprdevicas whlahemh BOILER-COME OHP OR 100,000 BTU)
Interactions air comairrimmus as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District?
❑Yes ❑No NF.W RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials 5505,25533 under Chapter understand
of the '
Cnlifo have
Health&Safety Code,Sections 25505,25533 and h 1 understand that if the building does not c umally have...at,that it is my rexpansibility to ntify thec.N.,of the namocmerns which must he mt pd.,to issuance of a CeNftcm ofOccupancy.
gent Date TOTAL: ISSUED BY:4e—
OFFIGF