25603TI N WITHIN RED LINES - USE BALL POINT PEN ONLY
AYYLIGAINI 10 FILL IN INFORM, O
CITY OF CUPERTINO PLUMBING. MECHANICAL.
BUILDING DIVISION APPLICATIONIPERMIT BUILDING PROJECTIDENTIFICA'TION
PERMITNO.
L V V
BUILDING ADDRESS ^: �p/�� '. 1��JJ��
10-712— aOC W(„w74, Dk
UNIT# LOT#
SANITARY NO.
AM IIyyCATION SUBMITTAL DATE
llJ���
OW1 SNAME: I)AV PHONB:
CONTRA
'OR'gjJ LIC NO:
G
NIC
El
CONTROL p
C1119YCf/LNGINEER: LIC NO: ADDRESS: O74
I
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
BUILDING PERMIT INFO
gLDG PLUMB MECH
IhT/aF
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
I hereby affirm that I unfocused underprovisiots ofartfun r9 (rommencing with
Section]003)nf Divisinn3 of the Business end Professions Cade.e dmylicrose isin
full forceanda��nd effect.if#F71 �,'jQ
Licentt Lic. M
PANELS
UP TO 203 AMPS
^�s.�
wr
Oma Contraclar
I / ARCHITECTS DECLARATION
1201 - 1000 AMPS -
OVER 1000AMPS
SQ. FT. FLOOR AREA
E/SQ. FT.
1 understand my plans shall be used as public remands.
SIGNS ELECTRICAL
Licensed Proleaai... I
OWNER -BUILDER DECLARATION SPECIAL CIRCUTFMISC.
1 hereby affirm the, 1 an exempt from the Contractor'. License Law for the
following reason. (Section 703 IS, Business and Professions Code: Any city Or county
TEMP. METER OR POLE INST.
which hatches a Permit to construct, Wer. improve, demolish. or repair any income
prior a its mmura, Win raid. theepplicant forxch pcmdt to file R signed salment
POWER DEVICES
that he is licensed pursuant to the provision of the Contrecurs License law (Chapter
9(commencing with Section 7000) of Division 3 ofibe Business and Prifessian Code)
or that he is exempt therefrom and the basis forte alleged exemption. Any violation ofan
Section 7031.5 by y applicant for a permit subjects the applicmt to a civil penury of
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FI%TURES
VALUATION
W
2Lee r
not more Nan five hundred dollars (5500).
❑ I,as wnerofthepmp ny,o myemploywswithwMesnthcirsolecompensection,
NEWRESIDENTIALELECTR _SQ.FT.
STORIES
TYPECONSTRUCOON
willdo the work.mdthc snemum iismtimmnded eroRexd forxle(Sec.7o44, Business
and Profession Code: The Connector's License law does not apply an an owner of
property whobuildsorimpmves thereon, and whodoes such workhimselforthrough his
wnemployees, providedthat such improvements munotintendedoroffired forici If,
OCC GROUP
RES.UNITS
how er,hebuildingorimprovemmtismldwithinoneyeuofwmpletim,Neowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ hasownerafNe ProPc^Yamexclusively canvxting wind licensed cantncmnto
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
connect the project (Sec. RWa, Business and Profession Code:) The Convector's
License law docs nut apply u an Ownerofproperty who buil he, improves thereon, add
PERMIT ISSUANCE
FEESUMMARY
whoconnects fm such projects withamomacens) licensed parsuanuode Conrtemfs
License Lew.
❑ 1 am exempt under Sec. . B & PC for this reason
ALTER -DRAIN&VENT-WATER EA)
BACK FLOW PROTECT. DEVICE
TSID
SANITARY Y_N
RECEIPT k
Owner DauDRAINS
WORKMAN COMPENSATION DECLARATION
❑ Ihreby effinn thetlhave acertificate of mnxnuo self-inure,wRttrtificete of
Wmkere'Compcnsetion lnurancenr eccrtified ropy Nereof(Sec.3g00, Lab CJ which
covers employee's under this Permit.
n al
Poliq#
-FLOORROOFAREA. COND.
, ,
F{ - E p
1
GAS- .S -I C. S.
SCHOOLTAX YN
RECEIPT#
PARK ME RECEIPT# N
BUILDING DIVISION FEES
Cam y
GAS - Y TE - )
PLANCHECK FEE
Cenifled copy is hereby famished.
GRADING FEE
Cenifled wpyis filed with the city inspection division. G EASEANDUSTRLWA
CERTIFICATE OF EXEMPE"FROM WORKERS'
G RASET
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need notbe completed ifthe Permitis fmonc hundrWdollam($EXE SEWER - SANITARY - STORM EA. 200F7.
or liwi
I cenlfy that in the parfarnamu of the work frr which Nis permit is issued, [mall
not employ any Jansen in any mermer m as to became subject to the Worker'
Compensation Lawsof California. Date
WATER HFATER W/VEJbGyELECI'R
WATER SYSTENITREATING
PAID
Dau Rmcipt#
Applicant
NOTICE TO APPLICANT:If, after making this Cenificme of Exemption, you should
NEW RESIDHNTIALPLMB. SQ. FT.
TOTAL:
homme subject to the Workers Coripenxtion provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be domed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
ELECTRIC FEE
I hcnby Rffum BOB Nem is a wnamation leading agency for the perfmmance of
the work for which this permit is issued (Sec. 3097, Civ. C)
A L:
PLUMBING FEF. a,
Under. Name
under. Address
QTY. MECHANICAL PERMIT FEE
I certify that I have read this application and stale that the above information is
correct. I agree to comply with.][ciI dy ordinances Rndsutelawsrelatingto
PERMIT ISSUANCE
MECHANICAL FEE 19
CONSTRUCTIONTAX
buildingeonsnectoo, and hereby a o ureprexntstivooftldsciry tocntmupon Ne
above-mentionedpnpeny for'n f nPurpoes.
-
ALTERORADDTOMECIL
(W e) agree m s v icy d keep hanrdess the City of Cupertino against
e ex which mayim y wayaccroeageimst said CityAIR
liabilities,judgman
HANDLING UNIT lT0 10,000 CEM )
inconsequence t T g thispenmit.
4.11
AIR HANDLING UNIT (OVER 10,030 CPM)
PAID
00 Sill mmref t tactor EXHAUST HOOD(W/DUC)
H DOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.000 BT'U)
Dam Receipt q
Will thenpplimalm future building Occup rm sure or handle hazardous materiel
n defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT(OVER 100j" BTU)
TOTAL:
Cade, Section 25532(a11
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the epplimmorfuuxbuildingoccupent uuaquionamordevices whichwtil
BOILER- COMP THIP OR 100,000 BTU)
®
Mzardous air contaminants as defined by the Bay Area AG Quality Management
BOILER - COMP (OVER 103,000 BTU)
_ • Q
District?
I
❑ Yes ❑ No
NEW RESIDENTIAL MECIL SQ. FT.
0" 1
((/,
I have read the hazardous materials requirements under Chapter 6.95 of the
W3
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 undenund Nm
^ y
if the building does not currently have a tenant, But it is my responsibility, to notify the
cupmm of the requirements which must be met prior to issuance of a Cmlficate Of
41�I �r LUj-tHlll4
Occupancy.
ISSUEBYBY:
Ownermituthonzedagent Date T
OH-IGt