25345 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPESION BUILDINU- PERMIT No.
APPLICATION/PERMIT PLUMBING C
BUILDING DIVISION BUILDING PROJECT If1ENTiFICA'1'ION 25345
BUILDINADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
6 O L UNIT# LOTk ���IL��j OWNERS NAME PHONE UNITCONst CORS NAME LIC NO {fes
(•00 T//E - (G. NIC CONTROL#
ARCHI1'PC 17ENGINEER: LIC NO: ADDRESS: ❑
o Ltx�FbeO CT. CSP a
#TACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ck2 Thereby affirm that l can licensed underprovisions ofaripler9(commencing with
00 Section 7000)of Division 3 of the Business and Professions Cade,end my license is in PANELS
a�F
fall fnnse Clasa Chuaffect
effect
4F,Z WVjO Lices CIL Lic.# 62c)394, UP T0200 AMPS 1 illi
m ti Date Contractor. 201-1000 AMPS
ZOyARCHITECTS DECLARATION OVER IOW AMPS SQ.FE FLOOR AREA I;/SQ.FT.
O Z'–Q I understand my plans shall be used as public records.
F.N.
Q ,� Licensed Professional
d'ed OWNER-BUILDER DECLARATION SPECIAL CIRCUEUMISC.
XOaU I hereby affirm that 1 am exempt from the Commerce.License Law for the ® '
W 3 O vFi following reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP,METER OR POLE INST, ^ ^ r
y which requires a Perming container,alter,improve,demolish,or repair any structure
:W}� prim to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
O that he is licensed pursuant to the provisions of the Comrector's License Law(Chapter I
a4o�' 9(tommeneing with Section 7000)ofDivision 3ofthe Business and Profession Code) SWIMMING POOL ELECTRIC e w _ .I UATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FUTURES
aSection 7031.5 by any applicant for a Permit subjects the spite=,to a civil penalty of v
El
more than five hundred dollars($500). FT. WINE
F� ElI,asowneroftheprnpeny,ormyemployeeswithwagesastheirsolecompenetiNEW RESIDENTIAL ELECfR on, _S STORIES TYPE CONSTRUCTION
wilidu the work,andthestrucwre is not iatendedoroffered for,oh,Sed,7044,Business
and Professions Cale:The Contractor's License Law does not apply to an owner of
property whobuildsorimprovesthereon.andwhodocssuchwork himselforthroughhis
own employees,provided that such improvementssre not intendedorofferedforsale.If, OCC.GROUP RES.UNITS
however.the building orimprovemem is sold within one yesrofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did out build or improve for purpose Of
❑ Las ownerof meproperty,emexdusively contracting with licenses convectors to QTY. PLUMBING PERMIT FEE FLOOD zoNe ANN
consumer the pr,act(see.7044,Business and Professions Code--)The Container's �—
LicemeLaw dcem
snapeane
plyto owrofpropetty who builds.,improves dereogand PERMIT ISSUANCE
License Loss.
forsu<h PrvJectswithacontrecNt(s)licensed pursuant tg the Contradols ALTER EA)License Lnw. FEE SUMMARY
❑ I um exempt under Sec. B&P C for this reawn BACK FLOW PROTECT.DEVICE O SIDE FF,ES
SANITARY Y N
Owner_ Date DRAINS-FLOORROOF,AREA,COND. RECEIPT'#
,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby I ❑ ers'Comparrmthntlhave a rancecertificate
or a coupe consenterof(Snsurgm Lab C.)Which
FIXTURES-PER TRAP RECEIPT'#
Workus'Campaosmion lnsumnceora certified copy thereof(Sec.7BW,Lab CJ whish PARK FEB Y N
ars all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
duty# BUILDING DIVISION FEES
Oceporty GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby Pomished.
❑ Candied copy is filed with the city inspection division. GREA$E/NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Cfhis section need not be completed ifthe Permit is for one hundreddollats($100) SEWER-SANITARY-STORM EA.200FT. ENERGYFEE
unless.)
I certify that in the performance of the work for which this panni[is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to became subject to the Workouts' PAID
Compenution Lawsof Ceiifomia. Data WATER SYSTEWMEATING Date Rmcipt#
07. Applicant
0. NOTICE TO APPLICANT:If,after tradingthis Cmificle of Exemption, TOTAL:
dyoushould NEW RESIDENTIAL PLMB. SQ.FT.
H become su comply the Worker's Compensation provisions of the Labor Code,you must
� > forthwith comply with such provisions or this pcnnit shall be deemed revoked. BUILDING FEE
RWi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that them is a construction leading agency for the performance of L: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.C.)
LL rr Leader's Name -
�/e
F' Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read This application end state that the above information is
0.i entreat.l agree w comply with all city and county ordinances and slow laws refining 0 PERMIT ISSUANCE MECHANICAL FEE
huilding construction,and hereby auNorim representatives of this city toeawrupon me CONSTRUCTION TAX
U 'Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless The City of Cupertino against
liabilitiesjudgments,costs and expenses which may in any wayacetae againtsaid City AIR HANDLING UNIT(TO ULXT0 CFM)
nuquence of the granting Of this pemdt.
-
AIR HANDLING UNIT(OVER 10.000 CPM)
C'O–
Signature of Applicant/Contractor pate EXHAUST HOOD(WMUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or future building occupaat store or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(x)7 VENTILATION FAN(SINGLE RESID)
Cl Yes ❑No
licamorfcture building BOILER-COW(3HP OR 100,000 BTU) al
ISSUANCE DATE
Will ghee
pp goccupan[use equipmemordevices which emit
hazardous airY'•
contaminants as defined by the Bay Area AG Quality Management BOILER-COMP(OVER 100,000 BTU)
❑ NT
Donner? fPk A l o
Yes ❑No NEW RESIDENTIAL MECH. SQ.Ff.
1 have read the hazardous materials requirements under Chapter 6.95 of the
Aifomia Health&Safety Code,Sections 25505,25533 and 25534. I understand that dslll�/Ik11S
if
the huildingdoesnotments currently[divestment,be Natitismyresponsibilityto enotifythe
occupant of the requirements which must be met prior or issuance of a Certificate of
Occupancy. N
V
Owner or emhonud agent Date TOTAL: ISSUED BY: