25130APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
-- -- --- -BUILDING-KLRCTRICAI. PERMIT NO.
CITY OF CUPEAPPLICATION/PERMIT PLUMBINMECHANICAL I 25130
BUILDING DIVISSIOIO NO N conn nwc onoG. - naa`T 1Oual1Ha1vTrilN
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PHONE:
LICENSED CONTRACTOR'S DECLARATION
QyZ Iherehyufflnn Nut l am licensed under inovincro.fCTepmr 9(commencing with
1400 Section 0000) of Division 3 of the Business end professions Code, end my license is in
5bE full mr.md effcn.
QQLicense Class Lie. #
N�y Date CnrILmCIOr
F,0„K ARCHITECI-SDECLARATION
OZ -0 I mmersund my plans shell be used as public recnrda.
r^Q o' s.....y]]] Licensed Professional
'�yq1 tY6 OWNER -BUILDER DECLARATION
yxOia F 1 hereby affirm that I an exempt Tom Ne Contractor's License Low for the
W3LLy following mason. (Section 7031.5. Business and Professions Code: Any city or county
(_ g which mluims a Permit to construct, alter, improv. demolish, or repair any stmeture
2};� prior to iu issuance, also requires the applicant for such permiuo file a signed statement
ACL G p that he is licensed p.m., to the provisions of the Commacmrs License Law (Chapter
9(conmencing with Section 7")of Division 3 of the Business and Professions Code)
" ^y or Out he is exempt mctefirm and the birds for the alleged exemption. Any violation of
7, < Section 9031.5 by any applicant for a permit subjects the applicant to o civil Penalty of
4 not mom Nen five hundred Minor (SSW). a
m❑ Lasownensf thepropery,ormyemployec with wegeaestheirsolecomPensation,
a,3.. will do the, work,and the structure is not intendedoroffemdfariale(S .7(N44, Business
and Professions Code: The Controcmr s License Lew does not apply to an owner of
Popery who builds or improves thereon, and whodoes such wOhhimreUorthrough his
wnemployces.provided that such orprowearrentam, not intended moffevent formic. If.
however, the building or improvement is said within one year of completion, the owner -
builder will have the burden of Proving that he did not build or improve for purpose of
sole.).
❑ I, as owner of the propery. emexclusively contracting with licensed contractors to
construct the project (Sec. 7044, Businesa and professions Cade:) The Connacmr's
License law does not apply man ownerof popery who builds or improves thereon, and
t who contracts for such projects with a contracmr(s) licensed punuanuo the Contractors
Licame law.
11 ❑ 1 am caerm, under Ser. , B & P C for this reasop
WORKMAN COMPENSATION DECLARATION
1 hereby effrm shot 1 have a mrifcete of conscm to self-inmre, art a cep fico¢ of
�prker%ComPensation lmumnc<m accnified copy thereof(SttJSW, C)wNch
covers all employee's under this permit.
Policy#
Company
❑ Certified copyisherebyfumished.
❑ Certified cupY is filed with the city insptttion division.
CERTIFICATE OF EXEMPTION FROM WOR S'
COMPENSATION INSURANCE
(Thissection nttdmtbecomplardif the penrds is (Drone hum dc`—(fl
or le I candy that in the perfomunce of Ne wok fm which this permit is its d,lsho
not employ any person in any manner so as to become subject m the rk
Z Compensation Laws of Califmmia. Daoc
Applicants
Ze�-� 2 NOTICE TO APPLICANT: If, Ater making this Certificate of Exemption, you shoo
rto become subject to the Workers Compensation pmvis ars of the Labor Cmde,you must
a; forhwith comply with such provisions or this petmitrshelf be domed revoked.
WCONSTRUCTION LENDING AGENCY
z Ihereby affirm shut there is a construction lending agency fm the perfomunce of
O the work for which this pentdt is issued (Sec. 3097. Civ. C.)
Lenders Name
Prr
Lender's Address
O LULL I cmEy that 1 have read this application and state that the above information is
correct l agree to comply with all city and county ordinances and state lows relating to
CA building construction, and hereby authorize representatives ofthis city to enter upon the
V 7 above-mentioned property for mspecdon Purposes.
.^. (We) agree to save, indemnify and keep harmless the City of Cupertino against
IimilifiesJudgmmu, costs and experua which may in my way nerve ugam tsaid City
in
onseyuence of the granting of this permit.
�' 3—i-9
Will me applicant or future building Occupant atore or handle hazardous ime,ial
as defined by the Cmern. Municipal Code, Chapter 9. 12. and the Health and Safety
Code, Section 25532007
❑ Yes ❑ No
Will the applicantOr future building accurate, on equipment or devices which emit
�mdous air mmeminents as defined by the Bey Arta Air'Queliry Management
vitt!
El Yes ❑ No
I have read the meardaus materials nomimmetta under Chapter 6.95 of the
California Health a Safety Code, Sections 25505.25533 it 25534. 1 understand that
if the building dues not currently have a tenant, that it is my maponsibility to notify the
Occupant of the raimmusents which most be met prim to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date
LOT#
ELECTRIC PERMIT
PHRMI'T ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECIR
IOTY.1 —: PLUMBING PERMIT I FEE I
ALTER - DRAIN VENT-WATER(EA)
BACK FLOW PROT� T. DEVICE
DRAINS-FLOOR,ROO AREA,COND.
FIXTURES-PERTRAP
GAS-EA.SYSTEM-1INC.4 LETS
GAS - EA. SYSTEM -OVER 4(EA)
GREASEANDLkTRL WASTE IN ACE
NEW RESIDENTIAL PLMB. / SO. FT.
TOTAL:
PERMIT
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 1M.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR IOLOXI BTU)
BOILER - COMP (OVER I W,OOd BTU)
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL:
,Sr—ow
SQ. FT. FLOOR AREA
31 cji [�1 �
Ai
(oras 4t -2.4
q1
FEE SUMMARY
FT.