25830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IL I .L TRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 25830_
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPWCATIONSUHMMITTfAALDATE
i UNITY LOT# 1 eq J
OW14 AME: • PHONE: T K'S NAME: LIC NO: N/C L CONTROL#
1
16K4& 3-4 NTR
1RCHITF.CT/ENGINEER: LIC NO: ADDRESS: / ❑
corvTAcr: pxarve: QTY. ELECTRIC PER IT FEE BUILDING PERMIT INFO
BLDG LI PLUMB MEC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATIONpPpL1ANCES-R D L )OB DBS ION
QWz I hereby affirm that l am licensed underpmvisionsof Chapter9(ccracia ingwilh
FJ 00 Seoion 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
C full force and effect.
6U License Class Lic.# UPTO A
Njy Date Connector - pS
Fy-zp ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.(,
z0 z-W I understand my plans shall be used as public records. R I AMPS
�rnFe� S E ECfRI
yyA.] Licensed Professional
OWNER-BUILDERthe Co ATION E AL Cu C.
3 F I hereby affirm that 1 am exempt fromm the Contractors LicenseLaw for the
ry�1 following reason,(Section 7031.5,Business and Professions Code:Any city or county P.M O POLE BEST,
vl ON; which requires a permit to construct.alien,improve,demolish,or repair any structure
NT.7 prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER D V S
ly�Q 0a that he Is licensed pursuant a Elie Provisions of the Contractor's License Law(Ohaper
��eW 9(commencing with Section 7000)of Dlvlslon 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC ^ VALUATION
or that he is exempnherefrom and the basis for the alleged exemption.Any violation of OUTLETSSWITCHESFIXTURES 1
Section 7031.5 pen - -
5 by any applicant for a Permit subjects the applicant to a civil
alty of 1
G not more
than five hundred dollars
yemp. NEW RESIDENTIALELECR _SQ.IT, STORI TYPE CONSTRUCTION
❑ athe wrk,andtheotractu nrmyempinyeeswithwegesrsthei(sole compensation,
W _ will do thework,andthe he Cont isnotim kende Law does not apply to
Business
and Professions Code:The Contractor's License Lew does not apply to an owner of
property who
yers,povalds idthat suchereon,andwhodoesauchwork himselfarthrough his
own employees,pingor improvement
evemenprovelwithinme ernoeoroffern.threats.If, OCC.GROUP RBS.UNITS
however,the buildingor improvement is sold within one year of completion,the owner- TO
builds ill have the burden of proving that he did not build or improve for purpose of
I,as ownerof the pmpeny,em exclusively contracting with licensed contncmnm QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
no ct the project(Sen.7044,Business and Professions Code)The Commetors
Licen Lowdoes morality man ownerofpropertywho builds orimproves thereon,and- PGRMIT ISSUANCE
who con such projects withacontractor(s)licenced pursuant the Contractor's ALTER EA
License Law. r ( ) FEE SUMMARY
❑ I am eumpt under Sec. ,B&P C for this mason BACK MOW PROTECT.DEVICE O T FE
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOT,AREA,COND. RECEIPT#
WORKMAN COMP ENSATIONDECIARATION SCHOOL TAX Y N
❑ Ihereby affirm that l have a certificate of consent to self-insum,or a certificate ofFIXTURES-PER TRAP RECEIPT#
Workers'Compensmion Insurance ora certified copy thereof(Sec.3800,Lab CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT#
Policy# ,/ BUILDING DIVISJOISAES
Company GASrEA.SYSTEM-OVER 4(EA PLANCHECK FES
❑ CattinessM
]copy is hereby fushed.
❑ Certified copy is filed withthe city inspection division. GREASEA STEN _ C CRT()R- GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE V1Il 1 I I� SOILS
COMPENSATION INSURANCE
(This auction need not be completed if the permit is for one hundred dollars($100) SEWER-SA ITARY-STORM EA.200 ENERGY FEE
or IesvJ qq''''''
I certify that in the peRormance of the work for which this Permit is issued,l shall WA .RMATpP,ry�T'
not employ any person in any manner so as to become subject a the Workers' _ AID w2
90
Compensation Lawsof Califomia. Date WATN Date R S
O Z Applicant
0. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FE TOTAL:
tibecome subject to the Worker's Compensation provisions of the Labor Code,you must
ai , forthwith comply with such provisions or this perrou"hall be deemed revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^� I hereby oferm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ,C.) L: �. ELECTRIC FEE
QO Lenders Name PLUMBING FEE
F Lender's Address QTY. MECHANICAL PERMIT FEE
0.V 1 certify that 1 have read this application and sham that the above information is ' MECHANICAL FEE /K
carrier, tegree[o comply with all city and county ordinances anJ state laws mlaring to PERMIT ISSUANCE
building construction,and hereby cult mprescmatives of this city to corer upon the CONSTRUCTION TAX
L)
(We)above-manomad progeny far inspection purposes. ALTERORADDTOMECH.
(We)agree m sive,indemnify end keep M1atmless the Cit of Cupertino against
hand ities,judgmen ,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in can, an nc the gmntiisoft l permit.
/ AIR HANDLING UNIT(OVER 10.000 CFM)
Signaw of plican4 ct ate EXHAUST4WD,(W/DUC) -
PAID
HAZARDOUSMATERIALSDISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOLKS)BTU) TOTAL:
Cade,Section 25532(a)?
11 Yes C3 No VENTILATION FAN(SINGLE RESID)
Will thea lieantor futumbuildin oecu BOILER-COW(SHP OR 100,000 BTU) ISSUANCE DATE
pp g pant uscequipmemordeviceswhichemit
Izardous air emasur cants as defined by the Bay Area Air Quality Management
BOILER-COMP(OVER 100,000 BTU)
- strict?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.PP. PAID I have read the hazardous materials requirements under Chapter 6.95 of the P A 9 D
California Health A,Safety Code,Sections 25505,25533 and 25534. I understand that
Fire buildingothe res not cents ly whit muste a aet Error my resance of
to notify of f 19
n, ��`
Fireceaurpant of the requirements which must tenant,met prior a issuance of a to notify he YIL &VI
Occupancy.
Owner m authorized agent Data ISSUED BY:
OFFICE
#