25012 7 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
/ CITY OF CUPERTINO " ' " PERMIT No. O
APPLICATION/PERMIT PLUMBING-MECHmriFiC
BUILDING DIVISION BWLUINC PROJECf IDRNfIPICAI'ION
12
BUIIfLDING ADDRjMS: /� SANITARY NO. API' ICA'DONSUBMIITALDATE
oC (J a/c,•✓ c�DNITp LOTH ��l-Q�
O ' S ME: pHO-E� COMfRACI'OR'S NAME: LIC NO:
CM JC>7 N/C CON k_
ARCHITEC A NGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ `9 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIP'T'ION
y�Z Ihereby offmn that l am licensed underpmvlsionsofC apter9(commencingwith
00 Section]000)of Division 3 of the Business and professions Code,seed my license is in PANELS
q full force and a t. •1 ((('''''' /n�
FZ Liceuse Clsss .p d I UP TO 2W AMPS
�L •d '\ �l/Ls/x/"' „(.
sn=y �� Connector 201-10(y)AMPS WW
Z8y- ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FI'.FLOOR AREA VSQ.FT.
I�Nunderstand my plans shall he used re public records. SIGNS ELECTRICAL ■ E D ' N�
licensed Professional L
OWNER-BUILDER DECLARATION SPECIALCIRCUff/MISC.
hge, I hereby affirm that I am exempt from the Contractors License Law for the IV P � p f�
s1�Dy followingamm�.(Seetion]o31.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. \ I 1`IlJll pL�r I
which requires a pr mdt m construct.alter.improve,demolish.or repair any structure ��
E }� prior m its issuance,alaurequires theapplicvntfor such permit to file a signed statement POWER DEVICES
G rep thm he is licensed pursuant to the provisions of the Conommes License Law(Chapter
Lion 9(eommencing with Section)000)of Division3 ofthe Business and Professions Code) SWIMMING POOL ELF.CfItIC pTION
nor
or that he is exempt herefrom and the basis for the alleged exemption.Any violmmid'
Y CZyaSection 7031.5M1 Ydntfapermit bjensthe applico aclvil penalty of OUTLT -SWITCHES-FIXTURES
50&
not more thanfvhundred dollus(f500).
NEWRESIDENTIALELECfR _SQ.FT.
wild.
Lusowner0phepropenymisnotmployceewifferedor Rolei(sole c0m.flusiion, STORIES TYPE CONSTRUCTION
a will do Nework.and e: he commerc inrendedm arm do for of apply to an Business
property
Professions Code:The Conwcmr s License Law does not apply to an owner of
propertywho builds orimprovesth at such improve winders such wokhimsfieredhroughhis
DEC.GROUP RES.UNITS
wnemr,thees,pmv dedori improvement
sold wisarenotimrofeco piano ,the comer-
however,illhav l the burien ofpmetnissoldedidnot year or improve for the owner- TOTAL:
builder will have the burden of Droving thus he did not buil)or improve for purpose of
ale].
❑ Lssownerofthepropeny,amexclusively romratingwiNlicensedconwdnrs t0 QTY. PLUMBING PERMIT FEEF100D20NE APN
comwa the pmjmt(Sm.71F4,Business and Professions Code:)The Contractors PERMIT ISSUANCI?
Licenm Lew doesnot npplytoan ownerofpropertywhn huilde orimproves theteon,and r
whommouctsfosuch projects with acommctonds)licensed pursuant to the Communes se Law.
License
ALTER-DRAINffi VENT-WATER(EA) FEE SUMMARY
❑ l em exempt under Sec. .B&P C for Nis reason BACK FLOW PROTECT.DEVICETFEES-
OUTS
IU
SANITARY Y N
Owner Dam RECEIPT'p
GOND.AREA,,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOLTAX YN
Thereby affirm thatlhnveacenificate of consent to selGinsme,orecenificvte of
FIXTURES TRAP RECEIPfp
FI
oren'CompensatiOnlnsuranceoracertifiedcopY thercat(SwJA00.LebCJwhich PARK FEE Y N
covee n all amp1nye�'s under thisp L GAS-EA.SYSTEM-1 INC.4OUTLETS RECISION
policyp 'T?Z/lcw,t,!/).? BUILDING DIVISION FEES
Company ((, g l/1�sT GAB-EA.SYSTEM-0VER4(PA) PLANCHECK FEE
❑ Cenified copy is hereby fumished.
`I Cenificd copy is filed withthe city inspection division. OREASfU+INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be,completed tithe permit is for one hundred dollars($10(p) SEWER-SANITARY-STORM EA.2001 T. ENERGY FEE
o lass.)
(certify that in the performance ofthe work for which this permit is issued,l shallm WATER HEATER WIVENTIELECTR .S
nemploy any person in any manner so us r0 became subject m the Workers' PAID
Compensation Lawsof Califomie. Data WATER SYSRIATREATING Dam Receipt If
Q Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption.you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
!/] became subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall W deemed revoked. BUILDING FEE
Y
II-) Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
O 1 hereby affirm that hem is a construction lending agency for the perfomuna of TOTAL: •S ELECTRIC PEE
the work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name
u.0 � Linders Addrcaa QTY. MECHANICAL PERMIT FEE PLUMBING FEE Z�S
I certify Nat 1 have tend this application and state that the above information is MECHANICAL FEE
7" cower.I Mom to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby audamim representatives ofthis city m aderupon the
VI CONSTRUCTION TAX
L) z move-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harmless the City ed Capeni tr against
liahilities.judgmemexpenses which and expenswhich may many weymcmeegainsteaid City AIR HANDLING UNIT(TO 10,000 CFM)
anseyuence a7.
mi gaNis Permit.
_� !:2 AIR HANDLING UNIT(OVER I0,010 CFM)
ignatum of ApplicanU ommcror Date EXHAUST HOOD(WIDUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt p
Will the aDilic.mor future building unmoral smrcor handle hodurims material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(n)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will Neapplicanmrtoure buildinguccupnmune equipment nrdevicnwhichemit BOIILR-COMP(JI{p OR IMMBTU)
harnrdovs air cotmmmearls as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Elau"BTU)
iavictT e
Ell yet EI No NEW RESIDENTIAL MECH. SQ.FT. ^
I have and the mustadous materials requimmcao ander Chapter 6.95 of the r�1ie
California Health ffi Safety Cade,Sections 25505,25533 and 25534. 1 understand that UN 1993
if the building does not currently have a tenant.that it is my responsibility to notify the
occupants of the requirements which must be met prior to issuance of a Cenificate of lxI'Y
Occupancy. 011 �I
Owner or nmh0riud egem Date TOTAL: ISSUED BY
Q '