25442 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELIT:PRIA PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25442
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: ./ A SANITARY NO. AaPPPfLLICATION"""SUBM��'f��TALDATE
O No / pAt UNIT# LOT% ea �/y�
WNERS NAME: PHONE: CONTRA j§SNAME: LIC NO: VV ✓
#I. N� N/C CONTROL#
ARCHITECf/ENGI F?R: LIC NO: ' (DDRpS$:/� N �w ` ~
7VY'�G�l,_O,r A-Y �, ❑
'ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE r ❑� El ELECT PLUMB MECH
LICENSED CONTRACTORSDECLARATION APPLIANCES-RESIDENTI 1O# ' 1/Y
���/
❑reZ I hereby affirm that l not licensed under provisions of Chapter 9(consomming with
�i100 Section]IX10)ofDivision 3of the Business and Professions Code,and my license is in PANELS
y� all force and effec
,z, Dattenx Clete Contractor a tw�zTT �sti� UP T0200AMP
Z Os`d'ir Z� ARCHITECTS DECLARATION OVER 10Q0 AA SS SQ.IT.FLOOR AREA $/SQ.FT.
p Z..p ee public records. /1\ /m
Py LiceneeJ Professional 9 N ICAL ('�f`r'/` `lq/ {•o(
��dd� ILDER DECLARATION P C CIRCUIT/M C.
K
�x'06F 1 hereby affirm that 1 am exempt from the Contractors License Law f the
W 3 p w following reason.(Section 7031.5,Business and Professions Code:Any city or co TE P.ME O NST.
(•'.rn which requires a permit to construct,alter,improve,demolish,or repair any eo-ucm -
yy�NYS prior m its issuance,also requires the applicant for such yemat to file a signed statement WERD S
N q�q 0� That he is licensed patsuant to the provisions of the Contracmr'I License Law(Chapter S WIMMIN PO L ELE IC
LXoIr.
9(commencing with 7000)of and
Division 3oflheBusiness add Professions violation of
®TIOON
ly�y
or hell exempt y plimand the basisfar
xubjeelleged exemption.Any violation of OUTLETS-S ITCH -FIXTURES
g, Y
Section 703 LS by any applicem fora permit subjects the applicensm ecivil penalty of
not more than Five hundred dollars($500).
a NEWRESIDE TIALELECTR _SQ.Fr. STORIES TYPE CONSTRUCTION
W m ❑ Lthe wner andtheropersy.ormyempended ortifwted forthei(sole c0mpev mien,
a will do[hewons ande: structureContractors License
Law dos not apply t am Business
end Professions Code:The ses tncmr'e License Law does not apply to en owner iof
s
propertywhoss,Idsofimprovesthereon,andwhodoessuchwork himselfedthroughhis
own employees,p building
or improvement rpmvementhincam earofcomoffered forints. r- OCC.GROUP RES.UNITS
howevepihe llhave the buren ofrovig thasolt
he did act
or improve
omm efor phe urpose f O
builder will have the harden of proving that he did no[build or improve for purpose of
le).
❑ I,as uwneroRhe propetty,am exclusively contracting with licensed contmcmrsto Qom' PLUMBING PERMIT FEE FLOOD ZONE AI'N
construct the project(Sec.]094,Business and Professions Code:)The Connector's
License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
who ronhacts forsuch projects with a contractors)licensed pursuant Conlractor'k ALTER DRAIN EA FEE SUMMARY
License Law. ( )
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTELT. VICE - OUTSID FF.
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF, H o
RECEIPT'#
WORKMAN COMPENSATION DECLARATION SculAX YN
ClI hereby affirm that l have a certificate ofconsent 0 self-insure,or a ociificate of FIXTURES-PER TRAP RECEIPT#
Worker%Compensation Insurance ora certifiedeopy thadmof(Sec.3800,Lab CJ which V N
covers all employee's under this permit. GAS-EA.SYSTEMA INCA OUTLETS RECEIFI'#
Policy# BUILDING DIVISKIWOoF.0%
to yGAS-EA.SYSTE OVER4 TE ECK JE
coined copy is hereby famished.
❑ Certified copy is filed with the city inspection division. ORFASEINDUSTRL WASTE LNTERCEPTOR GRADING
FELO
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed iftheperrit is for one hundred dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
.,lees.)
I certify that in the performance ofthe work for which this permit is issued.I shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so es to law ome subject to the Workers PAID
Compensation Laws of Celifomie. Date WATER SYSTEMTREATING
z Dace Receiptp
O Applies.[
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL Pit SQ.FT. TOTAL:
Ill) become subject to the Worker's Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
I hereby nf
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
fim that them is a construction lendingagency for
gy the performance of TOTAL: ELECfRIC FEE
U O oA
Ne work for which this permit is issued(gee.3097.Civ.CJ
Lender's Name PLUMBING FEE
Landers Address QTY. MECHANICAL PERMIT FEE
Q U 1 certify that 1 have reed this application and stele that the above information is
abuilding Iagree mcompty herebycityend coumyntativnofthis state laweroom due PERMIT ISSUANCE MECHANICAL FEE
UZbuilding herebyauNmiuimroseemtetives of Nis city to emerupon the
Uz abov(We)agree to sueyforinspection keep has. ALTER OR ADD TO MECH, CONSTRUCTION TAX
(We)agree judgments,
save,indemnify and keep hmy in the City of Cupertino against
inconsequent of the
expenses Prmit, nay in any way accrue against said City AIR HANDLING UNIT(TO IO,t100 CFM)
consequence of rhe grunting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Ilanature ofA lien ate MHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt It
Will the applicant or future building occupant store or handle hazardous materiel HEATING UNIT(OVER 100,000 BTU) TOTAL:
es de0ned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)?
11 Yet, 1:1 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP UHP OR Iffy"BTU) ISSUAIXE DATE
Will nair contaminants
is ro;building by the Bay Areequa Air or Quality Managemch ent
- A
hezmdous air contaminant¢az defined by the Bay Area Air Quality Menagemem BOILER-COMP(OVER 100,00)BTU)
) ♦,�11 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. FY!/
I have read the hazardous materials requirements under Chapter 6.95 of rhe - Cl/y 3
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that ut. `•`
if the building does not ammuttly have a tenant,that it is my responsibility m notify the Ghf
ocupant of rhe requirements which mus[be met prior to issuance of a CeriRcate of
benpanay. r
Owner or authorized spent Data TOTAL: ISSUED BY:
OFFICE