25218 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B 11. I -EL. RICAL PERMIT NO. ��
APPLICATION/PERMIT PLUMBING—MECHANICAL
BUILDING DIVISION HUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �—p� �/J y' SANITARY NO. APPLICATIONS BM���H sssTAALLDATF.
OI Cwe • I W UNIT# LOT# '/ /'► �aG
O AME: p}�NE:D CO RACI'OR' NA I O' /�
/ ✓ NPU CONT
ROLX/
• RCHITHUMNI 1 EER: LIC NO: A E :/,/I / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MEC
PERMIT ISSUANCE, w El f�Z L� /
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION l
ML
mmz I forebyaffm that Land liceacdunderpmvisiomofChasv9(commencing with
1400p Sectimn70W)of Division3ofthe BusinmsudPmfscions Codelicenseisin PANELS
U full
to
and off
4Vz License UP TO 200 AMPS
I--D< Dole_-J - ---Conlracm
1—r',Z_ ARCFIITELTS DECLARATION Z01.10110 AMPS SQ.Fr.FLOOR AREA S/SQ.Ff.
OC,q I understand my pians shall be used as public le<ords. OVER 1000 AMPS
SIGNS ELECTRICAL ~ 'I
K 77 Licensed Professional
V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. O�
xx 0 Wy 1 hereby affirm dual 1 am exempt from the Cri mom's License Law for the A A'
W3wFi following reason.(Semon]031.3.Business and Professions Cade:Any city or county TEMP.MET ER OR POLE INST. ! oV
ern.¢] whichre9uiresu pemitto consmet,alter,improve,demolish,or repair any structure POWER DEVICES
YYR if prior to its namme,alsorcquiresrhe applicantfor such Permirto file a signed statement
pp
00 that he is licensed punuamt m the provisions of Ne Contractors License Law(Chaser v -
�� 9mommencing with Section A100)of Division Sof Be Business and Professions Code) SWIMMING POOL ELECTRIC I V TIO
mnM1ul he is exenpnherefmm send the basis fonue alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
�z}
Section 7031.5 by my applicant for a Permit subjects the applicant to a civil ponshy of
not mom than five hundred dollen(f500). �.
� I,anwnernOhe yemp y g pe NEW RESIDENTIALELECIR _SQ.
yy p ❑ propenmic is la ceswiewa mmtheirsotec0m mesion, STO YPE CONSTRUCTION
y300 will dothe wons Codec he Contractor
Law
rdoes not
apply to an Rosiness /��
and Professions Codei&or The ves them .License Law des not apply to an owner of _ N
progeny wbo bui Ids or improves thereon and w ho tees s tach work himsel f ter through his
employeesilding edam wchimsvvemenmartne inmndedmoffemd theformic. r- OCOGROUP RES.UNITS
buwcveethe
ave[e burhnpmvcmcm issoldhe id noneyem or impromiogtheowner TOTAL: �(#
builder will have the burden of proving the he did not buil)or improve for purpose of .lam
vlal.
❑ Las the pmjmi(See e70,amemlusis and Professions
s Coate:) One nmacnrsm QTY. PLUMBING PERMIT FEE Fl.00D ZONE APN
construct the pmjm(Sec.7043,easiness and Rvfemions Code:)'Bm Contractor's
License trawdforsucupplym a nowuernfprnpeny wh0sed pumimprothe eereon,und PERMIT ISSUANCE
who Limme Law,foauch pmjenawit bconwcmr(e)licensed pursuantmlhe Conmctors ALTER-DRAINA,VENT-WATER EA FEESUMMARY
Licenx Lew, l )
❑ 1 mm exempt under S . ,B&P C for this meson BACK FLOW PROTECT.DEVICE OUTSIDE
Owner Date SANITARY• YN GRAINS-FLOOR,ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihereby affirm thathaveacenificam of consemt0 self-inure,mracertificne of FIXTURES-PER TRAP RECEIPTN
Wmkes'Conpensmlen Insurance ora cssnified copy thereof(See.38M.lab C.)which PARK FEE Y N
covers sell employee's under this 1' GAS-FA.SYSTEM-1 INC. 0I1'fLETS RECEIPT#
Policy q W es 1 Y(e L Z BUILDING DIVISION FEES
Comryny� IN .C U aL O N' GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cmifiedcopyisherebyfumished.
Ccnified copy is fled wish the city inspection division. GREASBANDUSTRL WASTE INTERCEPTOR
GRADING FCC
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need amu completed ifthe permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM EA.200". ENERGY FEE
or lee.)
I certify that in the perfortnnnceofoo work for which his permit is issuetl,I shall WATER HEATER W/VFNTIELECR
nm empnon to any manner x m m become subject to Be Workers PAID
CompensetioglTAµ fC omie. Date WATER SYSTENITREATING p xeipdp
C) z Applicant �L41
z 0 NOTICE T APPLICANT:If,after making this Certificate of Exemption.you should NEWRESIDENTIALPLMB. SQ.FP. TOTAL:
f" > bce0vid,coect In the workers Conpevethissavisiommfeeconedavoked. man
� > forthwith comply with such provisions or this pmmil shell be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency forec performance of TOTAL: ELECTRIC FEE
U O Permit the work for which this peit is issued(Sec.3097.Civ.C.)
finders Name
U.
U Lender's Add.. QTY. MECHANICAL PERMIT FEE PLUMBING FILE #�U
1 certify that 1 have read this application and elute that the above information is
1 coned.l agree to comply with all city and county ordinances and state laws mJan.$to PERMIT ISSUANCE T/ MECHANICAL FEE
buildingc0amction,end hereby auemixrepmsrntativm of cis city do rnmr upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
G7 (We)agree m aove,indemnify and keep hornless the City of Cupertino ugairel
liabilities,judgments,costs and expenses which may in any way same against said City AIR HANDLING UNIT(TO 10,01)(I CPM)
in conn fh g nil. AIR HANDLING UNIT(OVER 10.010 CFM)
Sigl um of Applimn4Contracmr Dee EXHAUST HOOD(W/DUCp 214,�f 7so76
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) f^O Data Recedes
Will the applicant or future building occupant store or handle hassfdous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by he Cupertino Municipal Code,Chasan
Chapter 9.12,and the Health d Safety
Code,Sectitin❑Yw 2(n)+ ❑No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(311P OR 100.006)BTU) d`� ISSUppANCE DATE
. Will lairhe cont monis as defined
by the Bay Am
Maria ement Deck
Dimino us air contaminants a defined by the Bay Ala Air Quality Manegemem BOILER-COMP(OVER 100,0110 BTL)
Dialricl(
ID
❑Yes 0N NEWRESIDFNTIAL MECH.—SQ.FT. JUL 16
a b ss �aaaaaa
JUJUS
1 huvc read the hazmdous materials nolmo mrnts under Chaser 6.95 of the
California Health A,Safety Code,Sections 25505,25533 and 25534. I understand Nm y
ifthe building docs not currently have a¢nans,that it is myrespornibilitymndifythe _ l ur vwrr 111VU
om 8-61A
w c V/5 ihe retnS}u wJ ust be mel prior to issuance of C Cenifieate of W 1 1
Occu V�/� 70
ud -7-1c—93
OW •r or amhonud agent Dam TOTAL: 0 ISSUED B
OFF