25774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B uHAD—IN r'hLE IRI AI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL f� C 4A
BUILDING DIVISION BUILDING.PROJECT—IDENTIFICATION' LJ
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
-r �- 1
/� 1 r UNIT# LOT# 1/1
O NAME: PHONE: CONTR OR'S NAME: LIC NO: _ Y
✓Ice N CrV .S C'7 C Li/�# I SLq NIC CONTROL#
RCfII'IFCl/F INEE : LIC NO: J� ADD '� / IJ✓ate 1 �l
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
TAG EL PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTT OR'S DECLARATION APPLIANCES-RESIDENTIAL
ply%_ Ihcrcb,.ffmn thin lam licer,mmideryrovisimsul Chapter 9(commencing with JOB DESCRIPTION
W,00 Section T000)of Division Sof the 8mmessand Professions Code,and my license is in PANELS
F full fora and "
al m.
FLyOj Liccnac Class _Licit UPT02MAMPS
mQy Dae Control�� 201-TWO AMPS
%FOy- ARCHITECTS DECLARATION OVER IOW AMPS SQ.IT.FLOOR AREA S/SQ.FI'.
OZ-0
I understand my plans shall he used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X OiO 1 hereby alllrtn thus 1 am exempt form the Contractor's License law for the
1i131r-vFi following reason.(Section 7131.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which inquires a permit to consumer,Mier,improve,demolish,or repair any aumcmrc
� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
c:g p 0m that lie is licensed pursuam to the provisions of the Contractor's License Law(Chapter
2eoLL 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt hersmm and the basis for thealleged exemption.Any violation^( OU'I'LEIS-SWITCHES-FIXTURES /1f\DO
FLQ Section 7031.5 by any applicant for a pemtitsubjects the applicant m a civil penalty of
not more than five hundred dollars(55(p). `JJ
Cl ❑ 1.uownerofthepropeny.ormyemploymswirhwagesasthcirsolecompensatiNEW RESIDENTIAL ELECTR _SQ.FT.on, SIOR1ES TYPECONSTRUCf10N
i322 will dr the work,and the structure is not intended croflbred foramc(Sm.J044,Business
anJ professions CsMc:Thc Comraamr's t.iccnse Law dues not apply m a owner of
propenywhobuildsorimproves thereon,and whodoessuch work himselfortM1mugh his
hocmployms.proviced thasuch impmvmunisare not hisodedoroffared forsale.If, OCC.CROUP RES.UNI IS
wever,the building or improvement is sold within one year of rompletion,the owner- 'I Ol'AL:
builder will have the burden of proving that he did not build or improve for propose of
sale.).
❑ I,asownerofthepmprty,amexclusivelyconu tingwilFlicenwdcontmaorsto QTY. PLUMBING PERMIT FEE FLOOD80NE AIsN
construct the projcm(Sec.7144,Business and professions Cods.)Tire Contractor's PERMIT ISSUANCE
LicenseLawdceanot apply to ancamerofproperty whobuildsorimproves thereon.and _
whocomracts for such projects with aconuator(s)licensed pursuanuarhe Contmerrr'e
Liccnae Low. ALTER-DRAIN&VIiNT-WATER ••E SUMMARY
❑ I am exempt under Sea .B&P C for this reason BACK Fl.OW PROTECT.DEVICE s l 11 It OUTSIDE FEES
'SANIT I IL Y N
Owner Date RECEIPT#
DRAINS-FLOOR.ROOF,AREA.CON .
WORKMAN COMPENSATIONDECLARATIONm ON II L X Y N
❑ —hereby affirm than have asertigcam n(consemwsclLinsure,ora certificate of RECEIPT'#
FIXTURES-PER TRAP
Workers Compensation lnsurunce mra<eniged copy thereinf(Sec.3g00,tab CJ wM1ich PAR PEE YN
covers all employee's under this permit. GAS-EA.SYSTEMA INC.4 OUTLETS RLCEIIT#
Policy# BUILDING DIVISION RIES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenilied copy is hereby furnished.
❑ Cenificd copy is filed with the city inapedion division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('lhisuaion nein nut hewmplaul iNhe pemrir is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200PP. Q4FRGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER WNENT/ELECfR
not employ any person in ary manner am l peburL at the Workers' PAID
Cmmpensaion,,ly ws.&C-1—fir Doe �� / le 1 _ WATER SYSTEM[FREA']ING Date Receipt
Z Applicam ib •[tet_�a 1+��
Z NOTICE TO APPLICANIs.If.aper making this Cenilicae of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
00 become ssidecnurhe Workers Compensnion pownirns^f the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE �f
W [� CONSTRUCTION LENDING AGENCY SEISMIC ME
C� I herchyaffirmrhm them iso communion lending agency(.,,he performance or
U O the work far which this permit is issued(Scc.3092,Civ.CJ TOTAL: ELECTRIC FEE
Leader's Name O PLUMBING ME F lenders Address QTY. MECHANICAL PERMIT FEE
U I certify mho 1 have rad this application and state that the elrove rows refining
is MECHANICAL FEE
building —agree mon.comply
and hereby authorize
coumyordlancesand stamla enter
gto PERMIT ISSUANCE
UZ atswengcotoned construction.and frebyauthmiarepses. vas ofrbisciry mercer upon the
V z above(We)
to save.
mnify ind keep hasp ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to aeve,indemnify and keep M1amleas the City of Cupertino against
liubilitics,judgm Me.luandexpeaseswhicbma 'a any way avemeagainst said City AIR HANDLING UNIT(TO 10,OD0 CFM)
in uenc fncegr nti gofthispermit.
/7 AIR HANDLING UNIT(OVER 10.000 CFM)
Signature K AMlicanVContramr ate EXI IAUST HOOD(W/DUCp
PAID
IIAZARDOUS MATERIALS DISCLOSU HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material BEATING UNIT(OVER 100,003 BTU) AL'
as defined by the Cupertino Municipal Crete,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
c]Yes ❑No VENTILATION FAN(SINGLE RESID)
Will air
npplieamnramure building by themuse Area in Quality eswhichemit
BOTLER-COMP(311P OR IOLMO BTU) ISSUANCE DATE
ezaMous air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP(OVER U10,OW BTU)
aria? B
❑Ye [Ia No NEW RESIDENTIAL MECH. SQ.FT. A D
1 have read the ha>oarous materials regaircmcros under Cbaper 6.95 of the rr,0�
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that ,111#
if rhe building does nor crtrendy hove a tenan6 that it i.my/Cuponsibility m notify We
occupat rf t qw nos whi t be me Oriar nee of Certificate,of '
oeenpan,o ` an�lLA rat a/ (,`ll a.
IN f9111VV
Owner or umhry A agent m TOTAL:
ISSUED B .
OFFICE