25229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHANICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT
tlU11A1NG PROJECT IDENTIFICATION
BUILDING ADDRESg: [^_ SANITARY NO. A
P
P
LICATIONLk SUBMITTAL DATE
V� %J
�/ %L � NIT# - LOT# ,s2
OWNERS E: PHONE: ACTOR'S NAME: LIC NO: �I
isissix9 O N/C&0ArCON ROC#
�ARCHITF,CT GINEER: LIC NO: SS:
CONTACT: PHONE: BUILDING PERMIT INFO
ELECTRIC PERMIT FEE
/( BLDG ELECT' PLUMB MECH
V -2:5-3 - 2 e PERMIT ISSUANCE n
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
qmz Ihereby affrmthal l am licensedunderprovisionsofChapter9(comtoencingwith
POO❑ Section 7000)of Division 3 ofrhe Business and Profusions Code,and my license is in PANELS
4�U fullnse Clad effect UP T0200 AMPS LF / Uvj`T
F W License Class Lic.p i !! V'
4 pate Contrmwr 201-ItMIpAMPS
LM
z FQ M to ARCHITECT'S DECLARATION OVER 1 ` SQ.FT.FLOOR AREA $ISQ.FT.
O Z—q I undersand my plans shall be used as public records.
Orn M SIGNS
Q 4�� Licensed Professional
6 ffaa]] OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt from the Coni erous License Law,for the
W 3 W y fallowing reason.(Section 703 1.5,Business and Professions Code:Any city or county TEMP METER OR ENT, t
which requires a permit to construct.alter,improve,demolish,or repair any smicture .,
sY� prior to its issuance,also requires the applicant for such pemdnofile asigned statement POWER DEVICES
CIO that he is licensed punuaot to the provisions of the ComractoYs License Law(Chapter
4 LL 9(cammencing with Section 7000)of Division of the Business and Professions Code) SWIMMING POOL L ICS VALUATION
Rooe, or that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
QSection 7031.5 by any applicant for a permit subjects the applicant toe civil penalty of
not more than five hundred dollars($500).
q NEW RESIDENTIAL ELbftl STORIES TYPE CONSTRUCTION
yy ❑ Las ownk,mal lbesouclare imointended withwed bords(Se.704,LBsiness
will do fe work,and e: he Con actor's License Law does not (Sec.7044,Bus
and Professions Code:The Contractor's License Lew rices not apply to so owner of
property who h u it ds or i mproves thereon,and whn does such work himself or trough hl s
own employees,provided tharsuchimprovemenlsv nolinwndedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyear ofcompletion,lheuwner- TOTAL:
builder will have the burden ofproving the he did not build or improve for purpose of
sale.).
❑ I,asownnof the property,am exclusively contracting wird li<enseticonvecersro QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's PERMIT ISSUANCE
License law does not apply to an owner of properly who bui Ids or improve hereon,and
who commas for such projects with a contractors)licensed pureuanuo the Connector's
License Law. ALTER-DRAIN&VENT-WATER(HA) FEE SUMMARY
❑,1 ma exempt under Sec. ,B&P C for this reasonBACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
OwnerDate DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
• < WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm that have a certificate efconsent to self-insure,can certificate of FIXTURES-PER TRAP - RECEIPT#
Worker'Compensation Insurance ora<ertifed copy thereof(Sac.3800,Lab CJ FE
which PARKE Y N
n all employee's mdertois permit GAS-EA.$YSTEM-I INC.4 OIHLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section nmdnot becompletedifthe permit is foram hundred dollam($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit isissuM,l shall WATER FIHATER WNIESUELECfR
not employ any person in any manner so m to became subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTEM/TREATING Date Receipt#
O Z Applicant
z O NOTICE TO APPLICANT:If,a fro making Nis Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
ti
r+ . become subject to the Workers Compensation provisions ofdm#revokLabor,evok you must
t-' forthwith comply wird such provisions or this permit shall be eeed. BUILDING PEE
L17 A CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
U O TOTAL: ELECTRIC FEE
Ne work for which this permit is issued(Sec.309],Civ.CJ
Lenders Name
u" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I terrify that I have read Nis application and state that the above information is MECHANICAL FEE
�-' W correct.Iagreem comply wird all city and county ordinances and state laws relating in PERMIT ISSUANCE
P. building construction,andhereby authorize representatives ofthis city menterupon the
Vl CONSTRUCTION TAX
(„) ,Z move-me)agree progenyfor inspection ind purposes, ALTER OR ADD TOMECH.
(We)agree nt save,indemnify and keep harmless one City cr CLpertino against
Liabilities,judgments,costs end expect swhich may in any weyeccrue gunst sa; City AIR HANDLING UNIT(TO Ig000 CFM)
in consx, of the gmntinga rs it.
AIR HANDLING UNIT(OVER 10,000CFM)
S(nature of Appliesnt/Cn D EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant in future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12.end the Health and Safety
Code,Section 25532(a)1 VENTILATION PAN(SINGLERESID)
11 Yes ❑No
ISSUANCE DATE
Will the epplicantor future buildingoccupam useequipmenmrdeviceswhichenth BOILER-COM?F&WOR 100,000 BTU) PAID
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU)
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. JUN
U 21 1993
I have read the hazardous materials requirements under Chapter 6.95 of the ISI
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a tenant,that it is my responsibility to notify Ne CITY Vr Wrr n I ITV
occupant of the require ems which most be met prior to issuance of a Certificate of
Occupancy.
Owner or amhorized agent Dem / ISSUED BY:�