25161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION PLUMBING-MECHANICAL PGRMIT NO. w
sIHLDwc InvlsloN APPLICATION/PERMIT L
BUILDING PROJECT IDENT'IF'ICATION
5161
BUILDING�ADDDRESS: 1� 1� SANITARY NO. AP/P�LICATION SUBMITTAL DATI
`��L�C `CW Y CUNIT#W LOTp 1 _
OWNERSNAME: a ' PHON�O? COM,TRACTOR'S NAM wlw _LIC NO: N/C �D CONTROL#
ARCHITECUENGINEER: LIC NO: ADDRESS:
C- [.i�-II Jjt
lZ
CONTACT: - Cw.T" PHONESjp - BUILDING PERMIT INFO
QTY• IC PERMIT FEE
IZD `� BLQG- ELK, PL MECH
PERMIT ISSUANCE �I�I(\ ❑
LICENSED CONTRACT'OR'S D CLARATION APPLLWCES-RESIDENTIAL
004Z Ihefebyaffirrnthat l an licensed underprovisionacdChapter9(commencing with JOB DE N
POO Section Division 3mf Ne Businessand Professions Code,and my license is in PANEL;
��� full formica t.
Ia,Zm Lice e_C s Lic.# IIP TO 200 AMPS J_ � ��•�
Nay Dae Y Convect-c at
201-I000AWS � x✓ �
ZOn� ARCHITECTS DH RATIO OVHR TWO AMPS SQ.I'L FLOOR AREA $/SQ.FT.
O Z"n I understand my plans'luall be used asp r olds.
6 �3 Licensed Profeasim al SIGNS ELHCTRICAL —7 D I N
5C�V OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
O 4 F• I hereby affirm mat 1 van exempt from the Contractor's License Law for me
following reason.(Section 903L5,Business and Professions Code:Any city or runty THMP.METER OR POLE INST. ly
'rn a which requires a permit m contract,eller,improve,demolish,or repair any swetum il /I
WQ2 pnortoimissuance,also regame,lheapplicant forsuch permitto file asigned statement PoWHR DEVICPS Y
y) O that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter
41x 0 ' 9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWGIMING PoOL ELECTR /SAA LUA,LI(�'yyai.
onto h7031.5 by any fromand the besisfar me alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURHS i— S�
FZ¢ Section 903n iv hundred
doll rsr$500).tsubjoete the epplican[meclvll penalty of ,�..I1
G not more man five hundred dollars(8500). NEW RESIDENTIAL ELECTR S
W w ❑ I,asownerofthepmpM,ormyemployeeswithwagesastheirsolecompmsafion, Q.LT STORMS - TYPH CONSTRUCTION
M within mework,andthe swcturoisnotimended proffered forsale(Sm.90al,fosiness
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds m i mproves thereon,and who docs such work himsel f or through Ns
own employees,provided matsuchimprovementarre notimmodedoroffereA forsele.If,
OCC GROUP ftES,UNITS
however,the buildingorimprovement is sold within one yeafofcompletion,me owner- T T
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,asownerofthepmo ny,amexclusivelycmtmtingwithlicensedcmm ctorsw QTY,gISSUANCE
NGPERMIT FEE FLOODZONE APN
constmet the project(Sec.9044,Bus and Professions Code:)The Contractor's
License Law does not apply w an owner ofpropeny who builds or improves thereon,and �."
whocontranD forsuchprojects withaventractuds)licensed pursuant w the Contractors NT-
LicensoLaw. WATER(PA) /'� FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTS-15 M-ES
SANITARY YN
Owner Date- DRAWS-FLOOR,ROOP,AREA.COND. RP.CEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherebyaffimrthatlhaveacenificateofconsentioself-insure,UracerGfcateof FIXTURES-PER TRAP RECEIPT'#
Workers'Compensation Insurance oracertified copy thoomf(See 3800,Lab C.)which4. PARK FEE V N_
covers all employees under this permit, GAS-EA.SYSTEM-I INCA OUTLETS - RECEIPT#
P.Iir'# BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filM Wim the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section neednot be completed ifthe permit is furore hundred dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
class.)
I certify that in the performance ofthe work for which Nis permit is issued,)shall WATER HEATER W/VENT/ELECTR
not employ any person in any mammy an as to become subject to the Workers
PAID
Compensation Laws of California. Date WATER SYSTEM/TREATING Date Receipt#
Q z Applicant
z -0 NOTICE TO APPLICANT:If,after making this Certifcale of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t+ (A become subject to the Worker's Camparsooa provisions of the Labor Code,you must
�i ; fonhwim comply with such provisions or this permit shall be deemed revoked. BUILDING FEE taaati
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a 1 hereby offimm that them is a construction lending agency for the pertornance of
V O the work for which this permit is issued(Sec.3099,Civ.C.) AL. ELECTRIC FEE
Lender's Name PLUMBING FEE
0 rLender's Address QTY. MECHANICAL PERMIT FEE
LUI runty ty that 1 have read this application and state that the above information is
met.Iagree.comply with all city and county ordinances andstate laws relating to PERMIT ISSUANCE MECHANICAL FEE
Coj building construction.and armbyauthodeerepresentativesofthh'city w enter upon the CONSTRUCTION TAX
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
rte- (We)agree m save,indemnify and keep hennless the City of CLpromm against
'lities,judgmrn costsend expenses which they inary way eccmeagainst said City AIR HANDLING UNIT(TO IO,000 CFM)
ines,mmm of granting of thio permit.
AIR HANDLING UNIT(OVER I0,000 CFM)
Slgnatur of Appli actor, Date EXHAUST HOOD(W/DUCT)
PAID
H ,ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
III he efidicart or future building occupant score or handle hazardous material
as tl Fred ty the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00,WU BTU) TOTAL:
CM,Se into YSec32(e)1 0 N VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR I W,IgO Biu) ISSUANCE DATE
Will theapplicanm us
t orfuumbuildingmeansceequipment ordevices whichemit Al -
hazardoaa air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 11� A D
Diem<te
❑Yee ❑No NEW RESIDHNTIAL MECH. SQ.FT. a
I have read the hazadous trinomialsrequirements under Chapter 6.95 of the 'vU�9 0 1993
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand met
if the building docs not cumn0y have external,that it is my responsibility w notify me
occupant of me requirement,which most Ire met prior to issuance of a Ceni0cate of G 1 Y ur V V rrm I ll
Occupancy. `
Owner or aumoriem agent Dam TOTAL: ISSUED BY: