25908 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
. 1 A. PERMITNO.
LSITY O CUP1 -ERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 25908
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING AODREgS: ((/^T����/j--'�'1XL SANITARY NO. APPLICATIONSIJBMITTALDATE
2 O T{ �lF LOT« 11/t 0-Rq
ERS NAME. PHONE: CONTRACT'OR'S AME: LIC NO:
y N/C CONTROL g
R IITL'CT/ENGINEER: LIC NO: ADDRESS:
ONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE. BUILDING PERMIT INFO
T_ 1 PyUM� ME_CH
PERMIT ISSUANCE BUM-`
LICENSEDCONTRACfOR'SDECLARATIONAPPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyz I hereby affirm Nut l am licensed underprovisionsol'Chapmr9(cummrncingwith
P1{0IC�00 Section'Io00lu(Division 3mf the Busineas and Profusions Code,annd�mylicenaeism PANELS ///��� g.�^y
FF6u" fucemu CW sef�Lic.N -� "'�Z IZ` I DP T0200 AMPS K71 �WyL—
to ti Data Contractor 201-11100AMPS
Z04 ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA stsQL FT.
C Z' Q 1 understand my plena shell boosted reN
ed us public cos.
ry [,d SIGNS ELECTRICAL
44yy ..T LicensW Professional
gK ¢
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�xx'Oa V 1 hereby affirm Nm 1 am exemia from the GoC9 License Law for the
W 3my fallowing rcmor(Section
constr,Business and Professionsh,carAnyeai city or county TEMP.METER OR POLE INST,
Las NOa which equircsapermitmCom,Oeralbq improve,demolish,me.si,enyswcture
�Y� prionoits issuan.,ilso requites the applicant for such permiuo fileeaigned atatetnem POWER DEVICES
W C 0 that he is licensed pursuant ro the provision of the Contmaor's Lic<me Law(Chapter
9(Commencing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATI
or Nat he is exempnheafromand the basis for thealleged exemption.Any violation of I 00atea/
tKQ Scnion]031.5hyanyapplicanl fora permit subjects theepplieant too Civil penalty of OUTLETS-SWITCHES-FIXTURES
Q not more than five hundred dollars($500). NEW RESIDENf1ALELECUR _SQ.FT. STORIES TYPECONSTRUCI'ION
W m ❑ Lthe wrk,saihepropengormyemployswiNwegesmthci(Sm.7nmpcnsedon.
L will do the work,anJ the structum is nor imendedoroffetNfor We(5..]tWa,Buainess r
end Prof.tions Cade:The Consncmrs License Law dcax not apply to an owner of
property whnbuitibmimprovn therwn.an0 whodonsuchwork himselforNroughhis _
empinys,providW that such improvemenu urenotimendedoroffered forsele.If, t � �I z .�.. 'sflC .'GROUP RES.UNITS
however,the buildingorimprovemem is sold within oneyemofcnmpletion,the owner. T \ ( ('1 II 1�
builderwill have the burden ofproving that he did not build or improve forp.Moseof t I/ P a ll'.�.
sale.). TY. PLUMBING PERMIT FEE �oyD APN
❑Construct
the tt project
(Sropeny.l,Business
�ss and Professions
C deemed Contractor Q
nense aw oesubl(Sec...0 Business and Professions Code:)The timmo .ruedtor's PERMIT ISSUANCE
Tr
Licence Lawd.rsuch porjeo with acrofpropeny whobuildsorimproves thereon.and
wicerve racy forsuch projcenwithacontrector(s)Iicenud pursuunOothe Convanols ALTER-GRAIN&VENT-WATER(EA)
Li.nu Lew. FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this rcmon BACK FLOW PROTECT.DEVICE. OGTS
SANITARY Y N
Owner Date DRAINS-FLOORBOOPAREACOND. RECLIPfN
, . , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have a cmiBcate edematous o self-imeum,or a cenificate ofRECEIPT If
FIXTURES-PFR'fRAP
PARK FEE Y N
Workers Compensation lnsurvnce oracenifieJ copy theomf(See.3800,Lab C.)which
Coven all employ.'.under this .it. GAS-FA.SYSTEM-I INC.4 OUTLETS
RECEIPTp
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER.4(EA) PLANCHECK FEE a
❑ Cenif¢dcopyishembyfumished.
Cenified copy is filed with We City inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FE13
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This seetionneN not be Completed ifthe permit is forone hundred dollars(3100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
or les.)
I.nify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELF.CTR
not employ any person in any manner m as to home subject in the Workers' PAID
Compcoaation Lawsof Califomia. Date WATER SYSTEM/TREATING Date Receipt#
0 Z Applicant
Z0 NOTICE TO APPLICANT:If,after making this CeniOab of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject to the Worker's Compensation previsions of the Labor Code,you must
Forthwith Comply with such provisions m this pemdt shall be deemed evoked. BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thatthem is a construction lending agency for the performeme of
U O OT ELECTRIC FEE t7(f
the work for which this permit is issued(S..309],Civ.C.)
Lender's Name
0 �! Lender's Address QTY. MECIIANICALPERMIT FEE PLUMBING FEE /a
v I Certify that I have read this application and state that the above information is MECHANICAL FEE
comeat.I agree to comply with all city end county ordinances and shite laws elating to PMNUTISSUANCE
IA buildingconswetion,and hobby solitaire representatives ofthis city menrcr upon the CONSTRUCTION TAX
-
U Z above-mentioned proper for inspection purposes. ALTER OR ADD TO NIECE,
(We)agree m save.indemnify end k. harmless the City of Cupmino against
liubilitin,judgmems,embnndexpcns myinany way accmeegaimtsvd City AIR HANDLING DNIT(TO lO,IXp CFM)
into. pe�ecoftbegrontingofthis
2 AIR HANDLWG UNIT(OVER 10,000 CFM)
I,...of ApplianVConmbI at EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0021 BTU) Do. R.eiptp
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAbi
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
P11 h—fidt—
CtNe,S.don25532(a)R VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will theapplicnnt orfatimbuildingoccupanmseequipmeatmileviceswhicherr0t BOILER-COMP(3HP OR 100,000 BTU)
mallous air Contaminants as defined by the Bay Amu Air Quality Management BOIL ER-COMP(OVER 100,000 B1 U)
ISVICf�
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. �yqa 7
1 have read the havarcious materials requirements under Chapter 6.95 of the - Y 0 O �O
if the
ulIng d &Safety Code.Sections 25505.25533 and 25534. I ity to notify
that
California@e buildingdon not currently Code hovel tenant,Sections
Oat it is anresponsibilitytonotify the
ocupant of the requirements which must be met prior to issuance of a Certificate of oily V1-I'f
ccupancy.
Owner m uuNorized agent Date ISSUED BY
I OFFICE