25368 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIr�EL A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL f� C O
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L J o
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1105 UNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NOS:DAI :
A e ^ f uwsI g I NIC CONTROL#
Is
ARCHCECT4s-NGINEER: LIC NO: ADDRESS r ❑
O. 0 36 Z
CONTper: PHONE r QTY. ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
\l O-X sap y.O' O PERMIT ISSUANCE BLDG El U. PL M MEC
TH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB 5 P1'ION
rvd.Z Iherebyuffrro Diisml amlice Busiscd ness and
Prifi nfC uxfiar Code9(it mmencise with �I
lllF--y0y]0 fail mne.norf Divuion3o[the Business and Pmfnxiom Cwle,antl myliansenm PANELS
tyU0g full forceand 1!7 _us UP T0200 AMPS
fyW License Class �� ;� Lie.# I
y<0• Date Contractor �' 201-1000 AMPS
FyARCHITECTS DEC ATI SQ.FT.FLOOR AREA b/SQ.FT.
Z
Z0 —
co1 undennswnd my plashall be used as public rtcoNs. OVER 1000 AMPS
OZ—❑
�yHW SIGNS ELECTRICAL
< $J Licensed Prnlrasinnal
XWee< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
°�diOaU 1 hereby affirm mat 1 am exempt from the Contmcmh License Law for the A
W 3 W vFi following rcaaon.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. v
5-° M which requiusaperminorores the
impmve.uchRemint orrepairanYswaure r. r--� # p
ne,< to thea ions for Co Remain License
Law
POWER DEVICES \ Itl\«///J7 FP yVy
prior requires pp pemti signed
WK 0O that he is licensed pursuant m tM1c provisions of the Contractor's License Law(Chapter
p' 9(wrmmcncing wilhSection]IXglufDivlslon 3oftbe B inesannd Professions Code) SWIMMING POOL ELECTRIC VA
WM, or that he is exempt-therefrom and the basis for the alleged exemption.Any violation of FIXTURES SWITCHES-
F Z G Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of OUTLETS- ATE _
5 0 not mom than five hundred dollars(b5W). NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPF:CONS'fRUCTION
wt. El1.a+owtmrofthepmp ny,ormyemploymswithwagessstheirsoleconip mmion,
will do the work,andthe structure isnot intended aroffeted forsale(Sm.]044,Business
and Professions Core:The Contractor's License Law does not apply to an owner of
propcny who builds or improves thereon,and whodoessuch work himselfonhrough his
emr.the building
i or improvement
sold within
ne your
ofoopletin.forsale.IL
OCC.GROUP RES.UNI IS
however. building Orden of pmcnt is sold within one year of completion,the ower,of TOTAL'
builder will have the burden of proving 1M1ar he did trot buil)or improve Int puryose of
❑ Lasowncrof the procetY•+mendusivelycontnning with li<rnsed rommcmnto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.7014,Dusiness and Professions Code.)The Contractors
License Law Anes not apply to an ownerofproperty who builds or improves thereon,andPERMIT ISSUANCE
whocomrmh for such Projects with acommmor(a)licensed pursuant m the C mtmamds
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I em exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,RtAJF,AREA,GOND, RT:CEIPTN
cover, WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑Workers
Coyaffmuhmlhranceve a ora cri fie consent to pytheruf(Ser.38 o.LahcertificateC) ich FIXTURES-PER TRAP RECEIPT'#
Worker Cmployees moerdbi,eorucenifed copy thereof(Sec.38M,l.ah C.)which PARK PIifi Y N
s all under this petnit. RECEIPT#
GAS-EA.SYSTEM-1 INC.4 OUTLETS ��
Policy# BUILDING DIVISION FE[S
Company GAS-EA.SYSTEM-OVER 4(HA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
}� Cenified copy is fled with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING -ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section neednot be completed Bribe permit is for one hundred dollars Clim) SEWER-SANITARY-STORM EA.200IT. ENERGY FEE
or less.)
I certify that in the perfmmanee of the work for which this Permit is issued,I shall WATER HEATER WNENHELECTR
not employ any person in any m o as to becnmc subject to the Workers' PAID
Compensation Lit—of Califnmis.manner
s WATER SYSTEM/IRCATING Date Receipt
O z Applicant
z � NOTICEI 0 APPLICANT:If.after making this CeftiReate of Exemption.you should NEW RESMEN'[AL PLMB SQ.FT. TOTAL:
VJ become subject mire Worker's Compensation Provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W (�
CONSTRUCTION i. . LENDING AGENCY SEISMIC IEE
I- z I hereby affirm than there emis struction lending agency for the performance of
U .con
U O the work for which this permit is issued(Sec.3097,Civ.C.) T A ELECTRIC FEE I
Isnda's Name
W F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have rear this application and ante that the above information is MECHANICAL FEE
W mi Ieg.,,,c.,Iywith all city uW<oanryoNinan<es and state leans rtlating to PERMITISSUANCE
I--' building concoction.and hereby radiative repourraativesofthis city toemer upon the CONSTRUCTION TAX
U7 above-mentioned prapeny for inspection purposes. ALTER OR ADD TO MECH.
C (Wc)agree to save,indcmni fy and keep hornless the City of Cuper Eno against
liabilitics.judgmems.costs and eacemes which mayor any way amru marcor it City A IR HANDLING UNIT(TO 10,000 CFM)
I.consequence of the granting of this pc.i,,
AIR HANDLING UNIT(OVER 10,000 CPM)
Si V Pare of AIicanUContmctor m EXHAUST HOOD(WNUC) PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,0100 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T
m defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25512(ap
El Y 5 ❑No VENTILATION PAN(SINGLE RESID) 171-
BOILER-COMP CHIP OR 100.000 BTU) ISSUE
Will the applicant in future huildingmcupanl u.+eeyuipmenmrdevicea whiANQ,E�Tchemit 1� Q� pp �J
haeardous air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER IW,(If%I IjTll)
•
District? ❑Yea ❑NoJUL 2 7
NEW RESIDENTIAL MECH.—SQ,FT. 1993
1 have read the harmonicasmaredils requirements undh
smile,Capmr,6.95 of the G�1Y JJ
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand that Ur UUrt t I
ifthebuildingrocsnutmnts whuh¢utenant,etatitismyaspnceoila rnotify the
Ooccupant of the requirements which must be mm prior to issuance of a Ccnifcvm of
cenpancy.
Owner m amhmi,rd agent Date TOTAL: ISSUED BY:
OFFICE