25768 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO H HAA -KL. 1'RI AI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25768
BUILDING PROJFICT IDKNI'IFICAI'ION
BUILDING ADDRESS /'�� ]���(��/� SANITARY NO. APPLICATION SUBMITTAL DATE
' "� pr_� I �— `•' ' UNIT LOT# t �`
OW N 13: 43
H E: C NTRACI'OR'S NAME: LIC NO:
• g e N/C CONTROL#
ITECI'/ENG ITER: Y`� LICA DRESS: ❑
` 0 8 L,
cow,rACD PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PP.RMIT FEE
G
ELECT PLUMB MECII
PERMIT ISSUANCE
f LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTIONp WrZ I hereby afrorbit l am liccaseduvderprovisimei.fairpter9(commencingwith
Pi]00 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
g full force and effect.
FZy License Class Lic.# UPT02MAMN `
race'on Dote Contractor 201-1000 AMPS
N„Z ARCHI=S DECLARATION SQ.PT.FLOOR AREA b/SQ.Fr.
CI ZZ-0 1 to derson d my plans shall banned m public records. OVER 1008 AMPS
r y t I4 SIGNS ELECTRICAL
6Y,� Licensed Professional
<
K GGOWNER-BUILDER DECLARATION SPECIAL CIRCUT/MISC.
°OaU 1 hereby afrinn no 1 an exempt from the Connection's License law for the
W 3
Ct y following mason.(Section 7031.5,Business and Prafeadmis Cede:Any city m mem, TEMP.METER OR POLE INST.
�0a which requires a perntiuo construct,Wier,improve.demolish,or repair any structure .
rn} priorto its issuance,nlsorequnsi the applicant for such perailto rile a signed alinement POWER DEVICES
yC that he is licensed pursuant to the provisions of the Contrncmr's License Law(Chapter
aX� 9(comrnmemg with Section 7008 f Division 3ofthe Businessand Professions Cale) SWIMMING POOL ELECTRIC VALU41il0
W_,y or Nat he ifemmpi therefrom end the basis l'or the Wlegcd enemptiOn.Any vi0laiion of \ a-
L.Z¢ Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of OU'T'LETS-SWITCH FS-FIXTURES Lith
'ay derfiveasohondmldollws($500). .
m action❑ I, wnerofthe]wop rty,ormyemployeeswithwugesastheirsolecompensation, NEW RFSIDIitJT1A1.ELECfR SQ FT. STORIES TYPE CONSTRUCT ION
ywill do the work,and the structure is not intended or offered for sale(Sm.70C4,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or impmves thereon,and who does such work himself or through his
ownetnployeea,provided that such improvements are notimersholmofferedfmaale.if, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcomplction,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepmpeny,amexclusivelyconlractingwbhlicens contractonm QTY. PLUMBING PERMIT FEE F'LOODZONE APN
construct the project(Sec.70 .Resines and Professions CWc:)The Cmm.lur's
License Lawdaesnotapplytoanownerofprgxnywhobuildsorimpmve.thereon,and PERMIT ISSUANCE
whocnntremsforsuch projectswithoconwtlor(s)licensed pursuant othe Contnsemes se Law.
Lice ALTER-UIiAI TP (E ) FEE SUMMARY
❑
License
am exempt under Su. ,B&P C for this reason BACK F10W P ICL \
ANITARY YN_
Owner Date— DRAINS RECEIPT#
DRAINS-FLO F,A`R
WORKMAN COMPENSATION DECLARATION Cf1OOL TAX YN
Ihembyaffinnihmlltoveacenificamofconwntwulf-insure,oracenificoteof F- URES-PERTRAP RECEIPT#
caken'Compansatinn Insurance or o certified copy thercid(Sce.3800,Lab C.)which PAR FEE Y N
coven all employee a under this permit. GASEASYSTEMPM Ji
RECEIPT'#
Policy# BUILDING DIV] ON FEES
Cilicipar, GAS-EA.SYSTEM OVER 4(RA) PLANCHECK FEE
Codified copy is hereby famished
Candied copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTRAP SOILS FF
COMPENSATION INSURANCE.
(This section need not be completed ifihe permit is fmone heretical dollen(5100) SEWER-SANITARY-STORM EA.300FT. ENE Y
err Ievs.)
I certify that in the performance Witte work for which this permit is issued,l shall WATER HEATER W/VENT/ELECPB
nor employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws Uf C.1ifvardw Dam WATER SYSTENPTREATING DeaIlls,%, Receipt#
O Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMEL SQ,FT. TOTAL:
� V) became subject o the Workers Compensation provisions of the Labor Code.you must
� , forthwith comply with each provisions m this permit shall be deemed revoked. BUILDING FEE Liaaa”
a �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the Performance of
V Z the work for which this permit is issued(Sec.3097,Co.C.) TOTAL: ELECM IC FEE
U. Lenders Nome PLUMBING FEE
�F Lenders Address QTY. MECHANICAL PERMIT FEE
[UkI1 certify Ban 1 hove reed Nis application uad sato ihm the abswe infonnmi0n is MECHANICAL IEE
correct.l agree to comply with all city and county mdimencea and state laws relating to PERMIT ISSUANCE
E" C4 huildingconswction,and hereby author representativesofthiscity be enter upon the CONSTRUCTIGNTAX
V7 Wnve-mentiond property for inspection purposes. ALTER OR ADD TO MECH.
G (We)agree loss,indemnify and keep borates the City of Cupertino against
Iiabdities,juJgmems.contend expenses which maybe any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in c orae..ine of the granting ofthis permit.
AIR HANDLING UNIT(OVER Io,n00 CFM)
iormu n pplati i m ear Dam EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 B'TU) Date Receipt
Will the applicant or name building occupant store or handle Interactions material BEATING UNIT(OVER 100,0BTU) TOTAL:
as defined by the Cupenim,Municipal Code.Chapter 9.12,and the Health and Safety 00
Cede,Section 25532(007 VENTILATION PAN(SINGLE RESID)
❑Ya ❑No
BOILER-COMP(3HPOR 100.0009TU) 1 SUANCE DATE
Will NI,meiconirsums ae building by the ruse Arepmirtt Quality,
Management ®p
vardous air contaminant az JefinW by the Buy Area Air Qunliry Mwagcmcnt BOILER-COMP(OVER 100,000 BTU) s C
.rim? ^ //'v �
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.Fr. ' ((D ,k� 3
veins
♦ J
I have read the hazardous materials requirements under Chapter 5.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 andersmnd thm
if rhe building Joe.nm currenely have n tenant,that it is my responsibility m notify the ..
exampsnt mine noiW emems which must be met Prior to issuance of a Certificate of
Occupancy.
a
Owner or authorized agent Data TOTAL: ISSUE
OFFICE