25140 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
B 1 DI -hLEG'TRI A PERMITNO. 0
CITY OF CUPERTINO PLUMBING-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT xuu.Dmcr OJfiCI'IDENTIFICATION
SANITARY NO. APPLICATION SUBMHTALDATE
BOILDINOWDRESS: }�
- / 7 B O ��� UNIT# LOT# X0- 3
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL#
at �m o 0
HITF.CT GINEER: LIC NO: ADDRESS' A eJ s GO A
to ❑
CONTACT: PHONE: QTY. CELECPRIC PERMIT FEE BUILDING PERMIT INFO
BLDG EL.IiCT PLUMN MUCH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Oyez Thereby affirmDivision
3 offi Basised ns provisionsions Cod.and
my Being with � `
�SOO Section moss7000)ndRfDivision3 of Ne Business and Profession Code,end my licmseis in PANELS
fullforte and effect. e.�
Licens Clus Lic.# SA/V'T r�U UPT0205AMPS
rFio=y Dua f_ 3 Contractor r 301-1000 AMPS SQ.FT.FLOOR AREA SISQ,Ff.
Z Ovtr'iz ARCHITECTS DECLARATION OVER 1000 AMPS
O Z a 1 understand my plans shell banned as public records.
6y W SIGNS ELECTRICAL
y�d J Licensed l4ofesound
IYy�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
°aO aU I hereby affirm that I nm exempt from from the Cmusubm's License Law for the
u�3yyfollowing Russia.(Section 7031.5.Business end Professions Code:Any city or county TEMP.METER OR POLE INST.
OQN J which reyuircs a pcwiuo construct.alter,improve.demolish,inceptor any swcam
prior to its issuance,uIs.requires the...icout far such man to file.siumdumement POWER DEVICES
that he is licensed pursuant m the provisions of the Contractors License Law(Chapter
yKQo 9(commencing with SeetionT000)of Division 3 of the Busincasand Professions Code) SWIMMING POOL ELECTRIC VALUAFI019
or that he is exempt and the basis for the alleged exemption.Any vidittionof OUTLETS-SWITCHES-FI%TURES
� �N
zG Section 7031.5 by any applicant for a pewit subjects the applicant to a civil penalty of '
C not mom than five hundred dollars(E500). NEW RESIDENTIAL F.LECIR _SQ.FT. STORIESTYPE CONSTRUCTION
y' p ❑ I.nownuofthepmpmy,ormyemploymwithwagesntheirsolemmpenution.
{y will dothe work,and the structure is not intended onoffered(arsale(See.7044,Business
and Professions Cade:The Commuora License Law does not apply to an owner of
property who builds or impmves Nerenn,and who does such work himulfor through his
employees,pmvidNnisuchimprovemesamnotintendedornffend(ornate.If, OCC.GROUP RFS.UNITS
ed m
however,the building or improvement is sold within me year of completion,the owner.
builder will have the burden of proving that he did not build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,asownerofthepropeny,am aclusivelyconvaztingwithlicensedcRnhacmmm
answer the project(SIC.Raul,Business and Professions Cade:)'Me Conuuctor's r.
License Lawdoeas not applyto m ownerofpropeny whobuildam improves Hereon,and P[RMITISSUANCF.
who contractsforsuch Projects with acommetor(s)licensed pumumuo Ne Commemrs ALTER-DRAIN&VENT-WATER UIA)k�n
FEE SUMMARY
Licens,Law,
[3l am exempt under Ser. .B&P C for Nis reason OUTBACK FLOW PROTECT.DEVICE SI ES
SANITARY Y N
Owner Date DRAINS-BOOR,BOOP.AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
Ihertby affiwthalheveecenificete of<munno tel(-Insure,oreartifice¢of FIXTURES PER.�Ap RECBIPT4
orkets Compensvtion Insurance orecenified copy Nereof(Sec.3800,Lath C.)which PARK FEE Y N
covers all employee's yyr��pee))Ms p5rpr GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy# IA/(:d` /lJry7"7N0—O Z'D/n 4-] r� BUILDING DIVISION FEES
ComyanI rare em me GAS-EA.SYSTEM-OVER 4( PLANCHECK FEE
— Ce nifiedcopyishereby fumrshed.
[3Cenified copy is filW with the city inspection division. GREASEANDUSTRL WASTE EPfORr RAD
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASE'I RAP l SO
ER
COMPENSATION INSURANCE
IThissudon nerd not be,completed if Ne pewit is formehundr>d do[].(11001 SEWER-SANITARY-STORM EA.200FT. ENFR
or less.)
I certify that in the performance of the work for which this pewit is issued.I shut] WATER HEATER WN ryLE
not empty any person is any manor,so as to become subject to the Workers'
Compensation Lawsof Califomla. Date WATER SYSTEMfGUi ATING Dam Receipt
Zz Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
r LC become subject to the Workers Compensation Provisions of the Labor Code,you must BUILDING ME�r fanw
hwith comply with such provisions nr this pewit shall he deemed revoked.
D-) Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of ELECTRIC FEE
V O the work for which this pewit is issued(Sec.3097,Co.C.)
LIB 715
Lenders Name PLUMBING FEE
0 FI.ender's Address QTY. MECHANICAL PERMIT FEE
V I certify that 1 have read this application end sate that the.hove infowmim is MECHANICAL FEE
contact I agrm to comply with all city and county Resonances and state laws Relating in PERMIT ISSUANCE
E-' building conswction,and hereby euNoriu repreunmtiveso(His cirymenurupon the CONSTRUCTION TAX
V7 above-mentioned prepeny for inspection purposes. ALTER OR ADD TO MECH.
C (We)agr,to save,indemnify and keep hamdess the City of Cupertino against
liebilides,judgmcnb,costseM<xpenuswhich mayors any wdydccmeagdntsdd Ciry AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of ApplicoMCmarocmr Dere EXHAUSTHO0D(W/DUC7) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.X00 BTU) Date Receipt It
Will the ep,he.,orfatum building occupantnorear handle haemdems mamnel HEATING UNIT(OVER 100,0[0 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532([? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicamer futumhuildingoccupant use equipmeotordeviceswhich emitBOILER.COMP(311P OR 10Q1100 BTU)
on air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) I1�t
islrictT A D
❑Yea 0N NEW RESIDENTIAL MECH. SQ.ITY.
1 have read the haeardous nn iaH repidero ems under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that 1I il)i Q 7
If the building does nm currently have vandal,that it is my responsibility to codify Ne JUN { 19
nesupmt of Oce requiurnenu which must be met prior to issuance of a Certificate of
;9
Occupancy. rat I Y U
Owner or authorised agent Data ISSUED BY: