25057 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UII:ISINC-F.I:F MTC` PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL 25057
BUILDING DIVISION BUILDING,Maim r HIRMI'IFICATTON
BUILDING ADDRESS: µ/w�f SANITARY NO. APPLICATIONSUBMITTALDATE
-r6 9 P✓T1 // VE. UNIT# LOT# �(
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
JrU t/A A/NI�6 A y 46
� N/C CONTROL
#
• ARCHITECTONGINEER: LIC NO: ADDRESS: Y E]
CONTACT: s-Jsa--�uNNr. J
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�F jy1 , /�IRuj Ny6 J2Z� PERMITISSUANCE BdrGq� ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby offirmthm lnmlirmsM undttpmvisiansofChupmr9(commencing with /
woop Section 7000)of Division 3 office Business and Pqmfeuions Code.and my license is in PANELS W `,a �e
UU full fo�rc�e and effcet.�v [[//`]�G��LI UPT02WAMP8 Tr` W R' ✓
F�yf Dole coc.ntractor
❑ Owe Contrumor 201-1000 AMPS 5 IT.FLOOR AREA "$/SQ,FT.
ZO,Z ARCHITECTS DECLARATION OVER 1000AMPS
Q
O Z-G 1 understand my plans shall be used as public mmrds.
r 4 k; I SIGNS ELECTRICAL
Licensed Professional
5y 6 OWNER-exempt RD[C ConumcON SPECIAL CIRCUIT/MISC.
°X-OyU 1 nherebyg..c affirm Nm 1 am exempt from the Contnmars License law for the
5 ur,o< following reason.(S«tion 7031.5,Business and l'rofessiom CWc:Any city or county TEMP.METER OR POLE FIST.
fJ�; which requires a permit to construct.alter,improve,demolish,or repair any sanctum
n}� akx o,mi,x...cc,also requires theupplicam bamch Permit to file.signedstatemem POWER DEVICES
y°j p that he is licensed pursuant to the provisions of the Conv.cmrs License law(Chapter
ddp�- 9(commencing with Section 7")of Division 3of the Business and Rafeuions Code) SWIMMING POOL ELECTRIC VALUATION
y�_y or that he isexcmpuherefrom and nobasis fonhe alleged exemption.Any violation M OUTLETS-SWITCHES-FIXTURES
LgQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 6,1 D O
not more than Love dollars(f3gy' NEWRESIDENTfALFLECIA _SQ.FT. TORIES TYPE CONSTRUCTION
K IC-� ❑ I,esowncmfNepmperry,ormycmploycexwith wagesmNeirxolecompereation,
yy22 will do the work,md the smatum Isom intended oroffned forsale(Sm.7044,Business
and Profess .Cade:The Cmrhaam's Liorme Law does not apply to an owner of
property who bu i I ds or improves thermq and who does such work hi rrcseU or through his
ownemployces,providedthm such improvements.mnot imeadedoroffetal forsale.If, OCC.GROUP RES,UNITS
however,the buildingor improvement is sold within one year afcompletion,theowncr-
builderwillhavetheburdenof that he did am build or int for f TOTAL:
proving prove puryoseo
le.).
❑cLasonstruct
ownerteNepm.70y1, esdusivelycontractingsClicensed coommenm QTY. PLUMBING PERMIT APN
nmrua the oes not(pm.o an
Business and Professions Code:)The Conuacmrs PERMIT ISSUANCE
ideans,Law docs not apply ct an owner of property who builds m improves Norton,anJ
who contracts Law.
such projects wiNacontrecroKs)littnxd pursuanno the Contractors ALTER-DRAIN&VFNT-WA ( FEE SUMMARY
License law.
❑ 1 em eacmpt under Sec. .B&P C for this reason BACK Fl.OW PROTECT.UEVIC' O IDE
Y N
Owner Date RECEIPT p
ca DRAINS-FLOOR.ROOF C
WORKMAN COMPENSATION DECLARATION TAX YN
❑Workers
Co perrm Nmlhave
rance acenicac opytheoxlGiec.380r Lab C.)c te ofwhich
FIXTURES-PERTRAP 1 RIeCEIPI'#
Wnrken'Cnmpensatiun Insurance oracenifeJ copy thereof(See.3800,Lab CJwbicb 'E YN
en all employee's under this permit GAS-FA.SYSTEM-I INC.4 OUTLfiRECEIPT#
Policy# --- BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCIIECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with On city inspection division. GREASEIINDUSTRL WASTE INTERCEFfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rad not he completed ifthe permit is Forane hundoddollars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfmaranceof the work for which this .it is issued,)shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner x az to haome subject to the Workers' PAID
z Compensstionlawsof Cnlifomia Date WATER SYSTEM/1'REATING Date Receipt#
Applica t
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RES]DENTAL PLMIL SQ.FT. TOTAL:
F' rrA becomesubjem to the Worker's Compemationprovisionsof Ne Labor Code,you mum .n
5 forthwith comply with such provisions or this permit shall be dcemed revoked. BUILDING FEE Q # d
a A CONSTRUCTION LENDING AGENCY SEISMIC FEE 5
z Ihereby affirm Oat them is.construction lending agency for the performance of
U O the work for which Nis pemdt is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
V. f-r Leader.Name PLUMBING MEF-- Larders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and state that the above information is MECHANICAL FEEcorren.)agree lm comply with ell<ily.M wuny ordinances and acme loan.rchting lm PERMIT ISSUANCE
f-' buildingeonswetion,and hereby authorise representatives,of Nis city mentttupon use CONSTRUCTION TAX
V memionW propcny fm inspmti0n purposes. ALTER OR ADD TO MECH.
)agree m sa ,indemnify and keep harmless Ne City of Cupertino against
liabilities,' dgmen osis andexpenseswhich may in anyway acme against said City AIRHANDLINGUNIT(TO10,00i
in conseque egranting of Nis permit.
AIR HANDLING UNIT(OVER 10,1100 CFM)
tare ofAicnnVCon EXHAUSTHOODIW/DUCT PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dare Receipt# p /fin
Will Nenpp ant or future building occupant store Or handle hazardous material HEATING UNIT(OVER 100,0110 BTU) TOTAL:
ea Acfined by Ne penins Municipal Code,Chapter 9.12,and the Health and Safety
Code.Sceti 25532(a)?
El Y<s ❑No
VENTILATION FAN(SINGLE RFSID)
❑
ISSUANCE.DATE.
Willthe.pplicanmrfuwre buildinguccuPam uxequipmentordeviceswhichemit BOILER-COMP(3fIP OR I00,(I(10 BTU)
hessrdons air contaminams u definW by the Bay Arta Air Quality Management• BOILER-COMP(OVER 100,gM)BTU)
P A E
District?
Yes ❑No
NEW RESIDENTIAL MECH.-SQ.FT. LAY 111993
I have read Ne felt'Coe,materials 5505,25533 under Chapter understand
of the
California Health&Safely Code,Seniors 25fi5.2S513 and 25534.1 understand that
if the buildingdocs not curtttmly have a tenant,Onto is my resprmmility N notify the CIII tar kaklrl]n 1116/
occupant of the requirements which must be met prior m issuance of a Cenificme of
Occupancy.
Owner or cdomizedngem Date TOl'AL: ISSUED BY� K� ����'✓