25142 _ APP.I-ICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOILIN..IsLEU71 RILA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. �C 'I �In
-BUILDING DIVISION BUILDING PRO]KC"rIDENTIPICATION J 1 4 L
BUILDING ADDRESS SANITARY NO. APPLICA1TION`SUBMITTALDAU
72 (0(01 UNIT# LOT# �1 r•
OWNII AME.: _ . • PHONE., RAC 'S fi LIC NO: N/C C10—NTR�OL
NIKUHILUOLING]NEER: LIC NO: y RESS: -,:,T ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ELECT PLUMB MECIi
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR inionsDECLARATION APPLIANCES-RF,SIDEN'I'IAL
OCL Ihereby afDivi,ithat lamlicensed Business prd PmfnsnfChapmr9(it(commencing I,IM1 JOB DESCRIPTION
a: fail fon 9X0)of Division S of the Business and Professions Cude,and my license is in PANELS �/ � �
Z ce full force erN effa't. fig`
I¢,Zw Licenx Li<.N UP T02X AMPS
m=,d„ Date Cocaine 201-1000 AMPS
Z FO ti Z ARCI IITF.CI'S DECLARATION OVER 1000 AMPS SQ,FT.FlAOR ARBA $/SQ.FT.
O Z_ 1 unJentanJ my plans shall be used az public mcoNs.
FQ y W SIGNS ELECTRICAL
X =h Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O y I hereby affirm that I an exempt from the Contractor's License Low forum
LL3LLof following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
5 which manures a permit to construct,alter.improve.demolish,or repair any moicmm
Cw}2 prior o its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
,9<0 z that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
1keLL 9(commencing with Section 9XAf of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC V���I�.}}jj'ATION
the
iu Z>n optionhai 7031.5sexiby anyap mmunfra permit suheallehWexemant to civil
of OUTLETS-SWITCHES-FIXTURES � A�i�
FLa Section door
five
any $permit subjects the applicannoecivil Penalty of ((�0
COma momthanfivethepro ay,or (5500).
NEW RESIDENTIAL ELF:CfR 5
o ❑ othe wrk,andeestracr.ormyempinded roofwed forsalei(Sec.comperusin. O�FL STORIES TYPE CONSTRUCf10N
will dothrwons and the stat Con is not intended La a does
apply to an Business
and Professions Calc:Thr vesdomon,and
Law does ar apply m an rough of
properlywyces.pdsorimproveslhemon,andwhodoessucdende oroffe ordtroagM1 his
ownemployees,ldingrimpreverdedthat nmis sold msartneyot ear oemoffered the onIL OCC.GROUP RFS.UNITS
however ill buildingorimprovementissoldwithinoneyear or improve for thrower- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ulcJ.
❑ La, he project properly,amexdusivelyromractingwith llIThe Contraorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
aacLicense
cwa the project applSec.y
gent Business and Rofcazi builds
Cale:)The Contractors ars
whocotrawdmrsuch pplymawith acofpropMywhosed pursumpmvea thereon,and PERMIT ISSUANCE
who contracts Lace fowuch projects with attmmactorts)licensed pursuant to Conuamors ALTER-DRAIN&VENT-WATER EA
License Law. WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&PC for this mown BACK FLOW PROTECT.DEVICE OUJ:SIDF FEES
SANITARY YN
Owner Dam DRAINS-MOOR,ROOF',AREA,COND. RF-CEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ ers Coyuf.rmtnInsureacmifwteofconythtrcuf(ce.380,LimC.)atmf FIXTURES-PER'1'RAP RECEIPT#
Worker'Co'boyee"Imbodri cmaccnifed copy thereof(Sec.JNX,Lab CJ which PARK FEE Y N
Coven ell employee's unJa this permit GAS-EA.SYSTIiM-1 INCA fITLLTS �'l. RECEIPT#
Company
BU DING DIVISION FEES
GAS-EA.SYSTEM-OVER ��
anpany FEE
❑
Codified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division, GREASEANDUS'IRL ASTIN ERCEPTOR
G I G iE
CERTIFICATE OF EXEMPTION MOM WORKERS' OR IFRE
COMPENSATION INSURANCE
(This section.ced not be completed if0e permit is forone hundred dollars($100) SEWER-SANITARY-STORM EA.2WET. ENERGX
lest]
I cenify'her in the performanceofthe work for which this permit is issued.I shall WATER HEATER W/VENT(ELECTR
not employ any person in any men ss to hecome subject m the Workers PAID
,z Compensation Lowsof Califomia. Date so WATER SYSTEM[TREATING Date Rcwipt#
Applicant
z 2 NOT IC27 TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RES]DENTIAL PLMB, S0.FE TOTAL:
(— y become subjectto the Worker s Compensation provisions of the Labe Code,you must
R, 7 forthwith comply with such previsions or this permit shall he deemed revoked. BUILDING Fl3E
per, Q CONSTRUCTION LENDING AGENCY SIiISMIC FEE
z I herchy affirm that there is o construction lending agency for the perfotmince of
U O the work for which Ihis permit is issued(Sec.3097,Civ.C) TOTAL ELECTRIC FEC
Lenders Name
OV Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that 1 have mad this application and state that Jam above inf rmanden is
conceit. lugree mcnmply with all city anJ county ordinances and smm laws relating to PERMITISSUANCE MECHANICAL FEE
I,I building construction,and hereby authorise representatives ofthis city menterupon the
L.) Z above-mention]prnpeny for inspection purposes. ALTERORADDTOMECIL - CONSTRUCTION TAX
(We)agate m save,indemnify and keep h e City of Cupertino against
liabilities,judgmems,cost nus ywayacerueagiimnsao Cily AIR HANDLING UNIT(TO 10,00CCFM)
to consequence of gof permh. m /
AIR HANDLING UNIT(OVER ILODD CFM)
Signature of ApplicanVC actor Date EXHAUSTHOOD(W/DUCI)
:PAID
HAZARDOUS LS monat CLOSURE HEATING UNIT(TO 100,000 BTU) :Dom ftt�TAL
Will the by'h Cofferdant cm
Municipal a:cupanter 9.nr handle Health and Safety
Code.Sedio 'he Cuperlino Municipal Code,Chapter 9.12.and 0e Health and Safety HEATING UNIT(OVER 100.000 BTU)
Code.Section 255J2(ep
0Yes ❑No VENTILATION FAN(SINGLE RFSID)
tlOILER-COMP ISSUANCE DATE
Will lair conwntorfumrr building by the Bay AreaAen Quality
Management (JHP OR IX,fNq BTU)
M1axaJous air cmmwninen¢az define]by the Bay Ante Air Quality Managemrnt BOILER 1X,000 BTU)
isWa! ut
El Yea El No NEW RESIDENTIAL MECH. SQ.FT. Ny
1 have read the hazardous materials requirements under Chapter 695 of the pq//I4 ��
if
building oes Safety
eeCode.Sections 255(t5at it is and 2553A. lunderstand that Tr7/'Ir
if the building rices not cunemly hove ucnant.that it n my mrearme of. er notify the ^//
occupant of the requimmenm which must bo met prior to issuance of n Ceaifiwm of V Y
R92-
arrnpancr. Cw—T(U/fy�NJNrk� t
Owncnu mthonud agent Dam TOTAL: ISSUED BY:
� IV 1 /3uCf/ANAN
ALIS. D. BOWYER 7/06/ - IAI WAV,
GENERAL CONTRACTOR C(�pT Ci9
PAINTING CONTRACTOR
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3481 EDEN DRIVE • SANTA CLARA, CALIFORNIA 95051 • (408)247-7217
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i GENERAL CONTRACTOR
PAINTING CONTRACTOR
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CONSTRUCTION CITY Of CUPERrlNDT E
3481 EDEN DRIVE • SANTA CLARA, CALIFORNIA 95051 (408)247-7217