25984 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO n. 1 " PERMITNO.
PLUMBING�MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILU25984
INIi PROJECT IUF.NTIFICeA'1'ION
RUIhDING ADDRESS: SANITARY NO. APPLUATIONSUBMITTALDATE
60T
l 02 2 D u�R
UNIT" LOTH I_"__CkI_T
SHAME: PHONE: CO RACroR'S NAM@ LIC NO:
N/C CONTROL is i
ARCHI'IIiCLANGINEI3R: LIC NO: ESS: ❑,
CONTACT. PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PCE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE x* ❑ ❑ ❑
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz I hereby affirm Nat l am licensed underprovisionsofChapter9(commencing with
�!00C Seen.7000)nf Division 3ofthe Business d P(mfessi Qs Code.and my license is in PANELS
FZW Lllf se C—lan/eR�ecl.- Tf—Lic.is ais„7 Q /2Z UPT0203AMPS /�y � ��\ Q
rn Q y ale 'rARCFII—'�—TECTS DECLARATION 201-In(1(I AMPS �"
SyZ OVER PS SQ.FT. OOR ARFA $`SQ.FT.
OZ-0 I undersand my plans shall be used us public records.
p ro t NS ELECTRICAL
4a,a Licensed RofeasipnaI
- 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
y�5dd'O c', I hemby affirm flus 1 am exempt from the Convector's License Law to the
v1+�a to following motion.(Section 7031.5.Businessand Professions Code:Any city or cc 'y TEMP.METER OR POLE INST.
tfJ o; which requproton to construct,after.improve,dcmnlish,or repair any sumo
pOWF. DEVI
Y�s�Y� prior to issuance.also rcquirtsthc applicant for such permitto file deigned sate in
TN25 iy a Q O that he is licensed pursuant m the provisions of the Contractor's License law(Chapter
of 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SW . .LECIRIC VALUATION
„y or that he is exempuherefrom and the hssisfor the alleged exemption.Any vmhamu of OUTL SWITCHES URFS 1 �O Owsiil
yKa Section 7031.5 by snyappiicaut fere permit subjects the applicant m a civil penWty.f ` LJiI
YF nm more than five hundred dollen($500). NEW R DENTIAL'ELECHt 5 .FT.
C� ❑ I.mowneroftheproperty.ormyemployemwithwagesastheirsalecompensation, Q STORIES TYPECONSTRUC ION
ii:Lowill do the work,and the structure is not intended or offered For We(Sec.7W,Business
and Professions Cale:The Com®ctm/s License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work himaelfm through his
employees,providedthatsuchimpmvememaarcnotintendedoroffer forsale.If, OCC.GROUP RES.UNITS
however,the building orimprovemnot issold within oneyearofoompletion,the owner.
TOTAL:
builder will have sM1e burden of proving that he did not build or improve for purpose of
°de')' PLUMBING PERMIT FEE FLOOD'LONE APN
❑ I,as owner oflhe propeny,am exclusively contracting with licensed convamesto QTY.
construct the project(Sec.7044,Business and Professions Cede:)The Communes
License LawdmsnotaM[ytomn nerofpmpenywhobuildsorimpmvesthereon,end PERMIT ISSUANCE
whocaramets fmsuch projects with a convactorts)licensedptaximnt mthe Cmnamemes ALTER-DRAIN&VENT�WATER EA
License law. (RAO FEE SUMMARY
❑ 1 am exempt under Sm. .B&P C for this meson BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
OwnerD°¢ DRAINS-FLOORRODFAREA. RECEIPT'"
. , ,
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑ Ihembydf fttlhaveamnricateofwn nitoself-insure,oraceedficteof FIXTURES-PER TRAP RECEIPT#
Workeri Compensation bvunnceora cenifmdcopy theraid(Ser.3800,Lob C.)which PARK FEE Y_N
coven all employee's under this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT"
Policy" BUILDING DIVISIONF I
I ad
Company GAS-EA.SYSTEM-OVER 4(E,O _ PLANCHECK FEE
❑ Cenified copy is hereby famished. t'
LID
❑ Certified copy is filed with the city inspection division. GREASR/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PFI:
COMPENSATION INSURANCE
(This section need not be completed Hire permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I rectify that in performance ofthe work forwhich this permit is issued.Imull WATER HEATER W/VENTIELECPR
not employ any prism in any manner so as in become subject to the Workers' PAID
Compensation Lawsef California. Date WATER SYSTEMTRFATING Date Receipt"
'Z Applicant
z�7�+ NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such previsions or this permit shall be deemed evoked. BUILDWGFEE'
a Q SEISMIC FEE
CONSTRUCDON LENDING AGENCY
= z I hereby affirm thra them is a construction lending agency for the performance of TOTAL: ELECTRIC TEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name PLUMBING FEE
O F lenders Address QTY. MECHANICAL PERMIT FEE
LULL I certify that 1 have mad this application and sate that the above inboard n is MI IIANICAL FEE
>" correct.l agree to comply with 01 city and county ordinances and sem laws relating to PERMITISSUANCE
Vbuilding construction,and hereby statistics mpmsenatives of this city to enter upon the CONSTRUCLIONTAX
above-mentioned property for impeotion poWses. ALTER OR ADD TO MECH.
(We)agree toe a demni fy and keep hu andess the Cupertino against
list it is and expenses which may in ways instaaici City AIR HANDLING UNIT(TO IO,pIX)CFM)
gmntin his permit.
.41 AIR HANDLING UNIT(OVER W."CFM)
of ApplicanUConvacmr Dat EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt"
Will the applicant or future building occupant some or handle hrmrdous material HEATING UNIT(OVER 100,(100 BTU) lD
on defined by the Cupcniam Municipal Code.Chapter 9.12,and the Health and Safety
Cafe,Sectimn 25532(x)7 VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will she epplicanmrfumrcbuildingoceupunt useequipmemmrdeviceawhichemit BOILER-COMP(3HP OR IM."RTU) n
w ah omarin inane as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A I V
izvin7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have rand the hmardous materials myuimments under Chapter 6.95 of the JAN 18 1995
California Health&Safety Gide,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a mount,that it is my responsibility to notify the CITY ur wrEkl
occupant of the requirements which must he met prior to issuance of o Contreras of
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BV: V/l/F1��1�3er
OFFICE