25244 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
x A PENM1'NO.CITY OF CUPERTINO PLUMBING. I
Bal PING DIVISION APPLICATION/PERMIT HUILUING FROJE(7FIDENTIFICATION
25244 JGA /
a BUILD'ING ADDRESS: SANITARY
% , SANITARY NO. APPLICATIONSUBMITTALDATE
/
s"1/S'' 1�l//,�E J2,__p UNITN LOT# ��
O�aE.$$[4AME CONTR R'SNAMH: IC NO:
N/C CONTROL#
RCIIITE GINEER: LIC NO: ADDRESS:
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�G ELECT PLUMB MECH
PERMIT ISSUANCE 0 E]
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB Df•SCRI ON
OPLZ Thereby afOrm Net lam licrnsed underpmvisions of Cheptn9(corrunencing with � ����
(^00 Section 7000)nf Division 3ofthe Business and Pmfeninns Cade,end my license is fn PANELS
qq'y full fora and !l
<UZ Lic CIassGs�Jl,ic.#. �-/ RIO 'r UPT0200AMPS
NQy Contrec �# 201.1000 AMPS
Fy I undersnM my plans shall
ARCH Ibe uud u public records..TECT'S DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
ZO OVER TWO AMPS
y C l+ SIGNS ELECTRICAL
6 � Licensed Professional
C that
I am exempt
from the ComTIONmences
SPECIAL CIRCUIT/MISC.
O y F I hereby affirm that I em exempt from the Contractor's Li<rnse law for Ne
1+1 Is.0Q following remon.(Snt1.7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
(r��J which requires a permit to construct,fact,improve,demolish,or repair any someone,�'P�i� priorto ie issuance,alsortquirts Nenpplicant(or such permit to❑leesigncd sts¢ment POW ER DEVICES
p'p0C that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
�eLL 9(consmencimg with Section 7000)of Division 3 ofthe Business and Professions Cade) VALUATIOG�{�y�
_y or shat he is exempt herefrom and The basis for the alleged exemption.Any violation of a< UTLEfS-SWITCHES-FIXTURES Section 7031.5 by Tiny applicant for a permit subjects the applicanuoocivil penalty of
K t] not more Non five hundred dollars(5500). NEWRESIDENTIALELECTR —SQ.FT. SWRI TYPE CONSTRUCTION
W � ❑ 1,asownerofd Wor ny,ormyemploymswiNwagcsnl irsolecompensation,
will dothe won,esulthe awetareisnot moo dedoroffemd forsale(Sec.70,14,Business
and Professions Code:The Corporates License Law does.1 apply to en owner of
propenywhobuildsor improvu thereon,andwhodaessuch workhimxlforNmugh his
moremployces.providedshataucb improvememsare not intendedoroffere,
d foradIL OCC.GROUP RES.UNITShowever,the building orimprovement is said within one yearnfcampledon,throwner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owneroRhe pmpeny,emexduvivelycnnvnctingwiNlicenxd convacmrsm QTY' PLUMBING PERMIT FEE ROOD ZONE APN
construct the project(Sec.1044,Business nd Professions Code:yThe ConlmetMs RM
License Law does not apply torn owner of property who tui Ma or Improv e�11!#er�
whoconrrecrs forsach projects with a contrectos(s)licensed pursumttovITTe v t - Af TF &VE R( A) FEE SUMMARY
License law. -
_ ❑ 1 um exempt under Sm ,B&P C it�� � — ❑.
11 ( u BACRO P B SANITARY Y N
Owner Data AREA,CO D. RECEIPI'p
WORKMAN COMPENSATION DECLARATION ^�^sA�T SCHOOL TAX YN
❑ I hereby affirm that l have a cenificam of consent toself-insur99,nraceniDA f RECEIPT#
Merl Compemmiort lmummce or a certifiedcopy Nemof(Sec.31m,j&¢t,)which PARK FEE Y_N
coven ell employee's under This .it. GAS-EA.SYSTEM-i INC.4 OUTLETS RECEIPT M
Policy ITBUILDING DIVISION FEES
Company OAS-PA.SYSTEM-OVER 4 EA) PLANCHECK FEE
❑ CertiOcd copy is hereby famished.
❑ Certified copy ix file)with N<ciry inspection division. GRRASFJINDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lithe Permit is farone hundred dollars(SIM) SEWER-SANITARY-STORM RA.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this permit is issued,l shell WATER HEATER WNFM/ELECIR
not employ any penton in any manner ad as to become abject m the Weak.'' PAID
Cnmpensmion Lawaof Califomia. Date WATER SYSTEM/IRGTING Dam Receipt#
Z O NOTICE TO APPLICANT:If,after makin this CeniOcato of Exemption,
8You shouts NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
Z
CO) became subject to the Worker's Compensation Provisions of The Lahr Code,you must
lam^ ; forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING ME
4 Q CONSTRUCT ION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a construction lending agency for the Performance of
V O The work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
Irnd I T Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
0 V enify Nu[I have read this application and state,that the stove information is MECHANICAL FEE
>4a correct.Iugrec to comply with all city and county ordinancncess and nem laws refining to PERMIT ISSUANCE
ty building construction,and hereby euthorim representatives of this caym enter upon the CONSTRUCDONTAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree save,
to indemnify and keep Ictrsaless the City of Cupertino against
Iiabilities,judgmenn,coats and expenses which may in any way accemagaidet said City AIR HANDLING UNIT(TO I G."CFM)
in consryvrn a of the grunti t it.
AIR HANDLING UNIT(OVER Ig000 CFM)
140
gnatdm of p cam/ tactor Dat EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt is
Will the applicant or future building occupant score or handle fi v ons returned
u defined by The Cupertino Municipal Code,Chapter 9,12.and the Health and Safety HEATING ON"(OVER 100,000 BTU)
Code,Section M32(a)1 VENTILATION PAN(SINGLE RESID) _
❑Yes ❑No
BODER-COMP(3HP OR 100,000 BTU) M.
IS ANfE•PA_TE
Will the epplicanmrfumre buildingacupantuxequipmrnmrtlevicuwhichemit p�� �'7 ] Q
hazardous air comuminanls as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) WO/Ap
'atnct1 w`Y9tl 9 p
� ❑Yea ❑No NEW RESIDENTIAL.MECH. SQ.FT. �i t7 9Q/�,�
1 have mad the haaerdous materials requirements under Chapter 6.95 of theC. y,/Y l.q- aV•�'V,l
iftheuil Hgdova Bafcur Coda Semi ans25505at it is and responsibility
1itytonmif Nat I'I/Prhf�
if the building does not mentacurrentlyw have a team.Net it is my responsibility a notify me
f
nccupam of the requirements which must be and prim m issuance of a Ccnifimm of
Occupancy.
Co n o m mal mixed agent Dam TOTAL: ISSUED BY: