25937 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ,I7 i- rLh PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25937
BUILDING DIVISION BUILDING PROJECT IDKN'I'IFICATIO%
BUILDING ADDRESS: (7� p SANITARY NO. APPLICATION SUBMITTAL DATE
C /� UNIT# LOT
OWNI; S A E: PI10NE: CONTRACTOR'S NAME: `` LIC NO:
�Cfx m e \ � t� Z O )9017 NAZ CONTROL#
1R IIT[CT/f OGINGIij ` AOS
CONTACT: l` PHONE: S BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
MECH
Jpa Cf f-Jrs' PERMIT ISSUANCE — R PL
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL DESCRIPTION
QWz Ihereby affirm that l am licensed underprovismarsol'C-hapter9 rommencingwiN
P400 Seen,,.7001)of Division 3.f the Business and Profession,Code,and my license is in PANELS
yyZW License
Clit eff��{{t.
6FZW fill force
wit l.—S Lic.M /201 UP TO2W AMPS
y6y Dale GOrTVBm.r42 k5
201-IoWAMPS
ZOr`i Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA
/n/ ders yplums beu as public..Ms.
OVER 1000 AMPS
�a� SIGNS ELECTRICAL
MM OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOiU I hereby affirm Net I am exempt from the Contractors Liceme Lew for N<
m 3 0 y following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1506 which requires a pemTii to construct.after.improve.demolish,or repair any structure
S YS prior to its Lssuanm,also requires the applicant for such pemai to file a signed state mens POWER DEVICES
"<0 that he is licensed pununm to the Provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC L VALUATION
a>, 9(commencing with Section 7")ofDivision 3 oflhe Business and Profession Cral
or that he is exempuherafrom and the basis far thealleged exemption.Any violation of OUTLETSSWITCHESFlXTIIRES
F Z Q Section 7031.5 by any applicant for a permit sublet¢ - -
the applicants.a civil pmolty Of
$SO
at mere Nan five hundred dollars(SSW). -2
CF ❑ I,mowncro(Ne t ,orm In eeswiN wa es astheirsole cont tion, NEW RESIDENTIALELECTR _SQ.FT. TORIES TYPE CONSTRUCTION
o PrsalatrY Ye^TP Y B pens,
will Jo the work,and the swclure is not intended watered mrsme(See.7(104,Business
and Professions Cale:The Caron rs License Law does not apply to m owner of
property who builds.,improves thereon.and who does such work himmlfor fl mugh his
own employees. that such
1 improvements are not intended or offered for sale.If, OCC.GROUP RFS.UNITS
pmvcn¢n
bolder will buildings den ofpmcm issold within one yew ofcimprove
frthepse of
bolder will have the burden of proving Nm he did not M1uiIJ or improve for purpose of
sale.).
❑ 1,as owner.f Ne propeny,amealusivelycontruming wiNli<rnsW c.ntncmmo QTPLUMBING PERMIT FEE FLOOD ZONE APN
Y.
construct the project(Sm.71X4,Business and Professions Codex The Comramm's
License Law doesnot apply to an ownerofproperty who buildsmimproves thereon,and A
PERMIT ISSUANCE
who wnlruela ficamch projects with aroarmm(s)licensed promem lathe Contractors ALTER I'A
License Law. 1 ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOP,AREA,GOND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOL T'A% Y N
• c❑eers Compensation
or it ica¢ofco,ythernf(Spsure,or Lab i.)whichteof FIXT' F3S PER TRAP REClill'1'#
Workerv'Cnmpensation Insurance oracenificdcnpy there.,(Sec.38W,Lab C.)which PARK FEE Y N
rsIleptployry',a underthis p� bECEIPT#
Policy KYVYI-.LV Y/Y'nt 79oZ7 GAS LA. YSTEM-I INCN .40IITLETShl i
BUILDING DIVISION FEES
Campion!% aa„ GAS LCA. STEM-OVER 4(EA) t P.ANCIIECK ME
❑ Cenificilm,nihorebyfumished.
UB—Cenilicd copy is flet with the city inspection division. GRF 5191 STRLWASMINTERCI?PI'Ogl- fTRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GSETRA�J�,-. 1 ILS FEE
COMPENSATION INSURANCE.
(Tfiissectionneednoi ccompletedif Ncpamitisf.ronchundreddollars(SIW) SEWL-'IITS'/Iftftl7lRY-STORM EA.200FI'. — ,NF.RGY PER
or les,,)
I cenifyord inthep aformance.fdre work far which this Permit is issued,Ishall WATER HEATER WNENT/ELECTR
not employ any person in any manner m as to become subject to the Workers' PAID
C.mperimtomlaws.f Califomia. Date WATER SYSTEM/IRRATING Date Receipt#
Q z Applicant
z C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
heroine subject to the Worker s Compensation provisions of the Labor Code,you must
> forthwith comply wit such provisions or this permit shall lz deemed revoked. BUILDING FEF,
C (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 heathy affirm Net Nem is a construction lending agency for the perf.rman¢of
the work fur which this Permit is issued(Sec.3097,Civ.C.) L: � IiLECTRIC FEE
U OLenders Name�' F Landes Address QTY. MECHANICAL PERMIT FEE PLUMBING ME r"
U I certify that I have mad this application and some that the above infomouoa i, MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE �A
Nbuildingeconniaion,and hereby auth.nm representatives ofthis city toenmrupon the CONSTRUCTION TAX
V above-mmetioned propcny,fs inspection purposes. ALTI7R OR ADD TO MECU
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabililics,judgments.susoaed expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10d0I4)CFM)
Mce of a Brvnti TN`s permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
'ignatre of ApplicinUCnmmcmr I Dm. EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IW,W0 BTU) Date Receipt#
Will the the Cummfumreicipal CWe,ng Chapter 9.12,
and le the Ihammus lth and moral HEATING UNIT(OVER IW,000 BTU)
as defined or the Cupertino Municipal COde,Chep¢,Y.12,end to I health and Safety
Cede,SmJ❑Yes El No VENTILATION FAN(SINGLE REST^`-
BOILER-COMP(3P:�r�- � Tr'I1 )� ISSUANCE DATE
Will the applicunlorfusrebuilding.ecupantumequipmentordevices whichendl lig T
bzrardous air contaminants as defined by Ne Bay Area Air Quality Management BOILER-COMPp.
Douj 11T;S,T . ossa,,, P A
❑Yes ❑No NEW RESIDENTIAL i'. :. SQ i P
I have rtad the harardous materials imi ircmems under Chapter 6.95 of the htbij lug
Califomia health&Safety Cade,Smions 25505,25533 and 25534. I understand that
if the building does not currently have a Tenant,that it is my responsibility to notify the Cqy
.setup m of Nc br,,ci rents which nmM be met prior nr issuance of u Cenifiewe of V Ur• Vf✓r i'r
71 mea
Owner.,mu degenl —� Om TOTAL: ISSUED
OFFICE