25796 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C TTY OF CUPERTINO HUMlifisli-JeLM R[CAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2579
� C (�
BUILDING DIVISION BUII,DINT:pRo.IF1CT1t)F1N'I'IFICA'I'ION LJ J
BUILDING ADDRESS: + L.// SANITARY NO. APPLICATIONSUBMITI'ALDATE
} ✓� + ygs'- ✓ UNIT# LOT#OWNERS NAME: PHONE: CONTRACTOR'S NAM F::y LIC NO: N/C CONTR .#
CI I'TECt :NGINH R: LIC NO: ADDRESS:
D, _r.Z A CK
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT(NPO
BLDG ELT PLUMB MECH
PERMIT ISSUANCE ❑ El I]
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
that IJOB DESCRIPTION
p00 Thereby safof
mision 3 ofth sed Business
and riovoons Coer and mmeneisewith
+10y0 fall( remid of Divisionlof the Business and Professions Code,and my license is in PANELS
full fna<und effect.
FZIy Licen.ae Class -^ I.ic.# ✓ y/ PTO 200 AMPS (,�/ FAX a I
6 N Dae Contmcinr �•a L 201-1000 AMPS
Zi,Z ARCHITIiCfS I1CLARATI N OVER IOW AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
OZ-0
I understand my plana skull be vud as public re,mrds.
MSIGNS ELECTRICAL
Licensed
Prnl'essinnal
lOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a I hereby affirm that 1 am exempt from the Connors License Low for the
W 3 LL vFi following reason.(Section 7031$Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which nes.irex a permit to amstrall,.lies,improve,demolish,or rcpan any structureprint n ata issuance,sedan requires the upplicnm To,such Pencil Bleusignedsntemerit POWERDEVICES
Mo that bn
e is licensed puuant to the provisions of the Contractors License Law(Chapter
o� 9(mmmencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iM or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F-ZQ Section 7031.5 by any npplicantfor u permit subjects the applicantuacivil penalty of
not more then five hundred Jnllne(SSW). NF.W RESIDENTIAL ELECfR _SQ.FT.
❑ I.mowneroftheproperiy,ormyemployeeawithwagaas NeirwlecomKmation, STORIES PE CONSTRUCTION
a3— will do hework,and the stracmmisnot intendedormffered herule(See.70PL Business
and Profession Cale:The Cormaro is License Low does not apply to an owner of
property whobmidliorimproves therean,and whodoes such workhimselforthrough his
own employees,pmvideddha[such impro.ememssm notimended oroffend hostile.If. I u, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,asownerofthepropeny.amexclusivelyconuactingwdthlicensedconuuctorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mvWet the project(Sec.7044,Business anal Professions Cade:)The Contractor's PERMIT ISSUANCE
License Law it.,timely m on ownerofp olitywh,builds orimproves thereon,antl
who contracts forsuch projects with a commuters)licensed pursuanuothe Cunractnr'e se Low. AI
License
ALTER-DRN&VENT-WATER(FA) FEE SUMMARY
[Il am eaempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT
WORKMAN COMPENSATIONDECLARATION SCHOOLTA% Y N
- Ihercbyaffrmthatlhaveacertificateofconemto self-intimin.sunificamnf FIXTURES-PER TRAP RECEIPT
ATn'Corfamealmn Insurance or a cenified copy thereof(Se,3800,Lab C.)which PARK FEE Y_N
,oveo,till employee's undenhis permit. G S-EA.SYSTEM-I INC.40VU.ETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company S E L V ( PIANCHECK FEE
❑ Certified copy is hereby famished.
❑ cenified ropy is filed with the city inspection division. EA S 1[R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
• COMPENSATION INSURANCE
('this section lived tat be completed if the permit Is for one hundred dollars Pilo( ENERGY FEE
or leas.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER WNENTryLECTR
not employ any person in tiny manner so sx, M1(Come ml'epIm the Workers' PAID
O z Campanian lysvaptf Celifomia Dm •� S WATER SYSTEM/1'RF,ATING Date Raeipt#
pplicum l( Ll ,44 .Ad-t, .
z NOTICE TO APPLICANT Lager akingthis Cerilica[eof(li emption,youshould NEWRESIDENTIALPLMB. SQ.PT. TOTAL:
I)) become subject o the Workers Compensation provisions of the Labor Code,you must
•`Cat' ; forthwith comply wi th such provisions lir this permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
rJ Ihereby affirm that bem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work far which this permit is issued(Sec.3097.Civ.C.)
ULender's Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
I certify that I have read this application and stale that the above information is MECHANICAL.FEE a correct. I agree m comply with all city and county Ordinances and state laws relating m PER MIT ISSUANCE
�-' building construction.and hereby authorize mpresematissn ofthis city toemer upon the CONSTRUCTION TAX
U 2 above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)ugme to save,indemnify and keep harmless the City of Cupertino against
liabililesJudgmem ostsandexperms which maymanys 5secrueagaWtsaid City AIR HANDLING UNIT(TO 10.030 CFM)
as, the g eating of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
E%IIAUST HOOD(W/DUCI')
nmuma ApplicanUCmn dor um PAID
IIA- RDOI MATERIALS DISCLOSUR HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the opplicam or future building occupant store or bundle hazardous materiul HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12.and the Ihollh and Safety
Code.Senior 25532(0)?
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 100,0(1(1 BTU) ISSUANCED E
Will theupplicam nrfuumbuildingoecupamuse equipmcmardevices whichemit p
razilaaus air contaminants tamints as defined by the Bay AreMP a Air Quality Management BOILER-CO (OVER 300,000 BTU) lA 9
iatdct?
❑Yes ❑No NEW RESIDENI'JAI,MECII, SQ.FT,
I have read the hazardous materials requirements under Chapter 6.95 of the My 8 3 �q y
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undeumn l that vsu
if the building does not currently have a[count,that it is my responsibility,to sooty the CITY ser VUr to I ITV ,
occupant of the requirements which mus[be me[prior to issuance of a Certificate of
Occupancy.
Ownermituthodzed agent a Dau TOTAL: ISSUED BY:
OFFICE