25720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING"VLECI'RILA, PI:RMrr NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�5 /�('
BUILDING DIVISION BUILDINGYROJECT IDEN'I'IFICAI'ION GJ c `
BUILDING ADDRESS:/. SANITARY NO. APPLICATIIOONSUBMfITALDAT
16,r,63 (i V G UNIT# LOT#
OWNER NAME: PHONE: CONTRACTOR'S NAMEaix LIC NO: /�—�•J
a p_� u NIC CONTROL
•A RCIIITECrpiNGINEER: LIC NO: ADDRESS: El
CONTACT: PHONE: QTY ELECTRIC PERMIT a FEE BUILDING P[RMIT INFO
BLDG EL PLUMB MtLy
PERMIT ISSUANCE ❑ ❑ ❑ I(Y�AJ\
LICENSED CONTRACTOR'SDnsm Cha TION APPLIANCES-
Qp�y Thereby affirm N:nlum licensed underprovisimnsnf Chap¢r9(armmencing with RESIDENTIAL TOB UESCRIPI'ION
[ 00 Section 9000)of Division Sof the Bailouts and Pmficomns Code.rod my license is in PANELS
full fa eve ands yI {rQ�a_'.JryV,1�
ha„Zul eve —Lic.py__zf UP T0200 AMPS
ay Date
I.
Contractor is[. 201-1000 AMPS
20yZ ARCHITECTS DECLARATION OVER 1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ—c I modemand my plansshall be used as public recmi
6yEj Licensed Professional SIGNS ELECTRICAL
�yeda OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
X c. 1 hereby affirm that I am exempt from the Contractors License Use for the If
Is131r-m¢ following rentor.(Seniors]031.5,Business and Professions Coda Any city or county TEMP.METER OR POLE INST. �
u'Om 3 which requires a permit to commit,alter,improve.demm eh,or repair any structure (I /t r� j
Iuu
, Ali"ok IN
WY2 prior to is issuance,don requires the applicant for such permit to file a signed statement POWER DEVICES I u\V/71 IBJ I�
,=<0 that he is license) t to the f the Contractors License Law(ChimerII II
u,_Qp pursuer Provisions SWIMMING POOL ELECTRIC ! pLUAT10
a,ON 9 gommencing with Section]000)of Division 3 of me Business and Professions Code) � ?
,_m or that he is exempttherefrom and the basis for the alleged exemption.Any violation of
FZ� Section 70313 by any applicant for a Permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES d Q
EEC not mom than Eve hundred dollars(SSW).
ce L:= ❑ I,as owncrol''Iheproperty,manyeandoyeeswith wages as lheirsolecompensaion, NEW RESIDENTIAL ELECIR _SQ.FT. S'rOR1ES TYPE,CONSTRUCT'lOD
a3— will do the work,..d Neanuctum isnot imendedmr.ffercd hostile See.70P4,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
progeny who mildsor improves thereon,andwhodoessuch work himselfnrihrough his
hoemployees,provided that such impmvementimenot intendedoroffered forsale.If, OCC,GROUP EAIN
wever,the building or improvement is sold within one yearofcompletinn,the owner-
builder will have the burden of that he did not build or TOTAL:
proving prove for purpose of
alcJ.
❑ Lasnwncr.UM1e pmpcmy,rem exdsively contracting with licensed c.nhuclmrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE
... ..met the project(Sec.7044,Business and Professions Code:)The Contmcmr's
License low Jens otapply loan owner.fproperty whobuildsa impmvc:1C1. n.end PERMIT ISSUANCE
whommmcts forsuch peojmn with a emanations)Retrad punuanuothConmetor's ALTER FEE SUMMARY
Lint.low. WATER(E/O
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE:FE-ES
YVN
Owner
Date DRAINS-FLOOR,ROOF,AREA.CONE. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ est'Coyaffirn Natlhave a urnameeAficam ofropydoerid(Sevent to csurc,orLab
Cdamor FIXTURES-PER TRAP RECEIPT#
Work,all cmplmycds ynJcsalhis Permit.
Policy
Naeof(Scc.)800,WbCJ which PARK FEE YN
Policyis a / ��V� GAS-EA.SYSTEM-1 INC.40UTLETS BUILDING DIVISION FEES
Company 177 g74 GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
ElCertified copy is hereby famished.
Certified copy is filed with the city inspection division. GREASE/INDUSI'RL WASTE 1NTERCFa'TOR GRADING Il3G
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
CDtiasuclion mecdnatbe,tinmeled ifthe permit is forme hundred dullimi 51110) SEWER-SANITARY-STORM HA.]WIT. ENERGY FEE
ar less.)
I cenifydmt in the perfmananceof the work for which thisperoun,issued,)shall WATER HEATER W/VENI/ELECTR
not employ any perum in any manna so as to become subject to the Workers
PAID
z Compensation taws of California. Date WATER SYSTE /1'
MRFATING Date Receipt#
O Applicant
0 NOTICE su j APPLICANT:Work If,Compensation
this vision ofto,thExemption,yooushould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F lq forthwith
subject m the Worker's Cwnpensadis Amus the of the lobar Code,you must
fmrthwilh comply with such provisions or his permit sM1etl be d«med invoked. BUILDING FEE
per, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
U C) the work fill which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
lender's Name
0 U tenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have read this application and star,that the above information is
•�" 0. corer.lugreewc°mply with all city and county.Ninanaaand staelawe relmingm PERMIT ISSUANCE MECHANICAL FEE
�-' rn building construction.and hereby authorize representatives mfthis city to cater upon the
U z above-mentioned progeny for inspection pmpoaes. ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(Wc)agree msuve,indicant ify and keep harmless the City of Cupertino against
I iuhi li lies,judgnmm.s,costs and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO I Odood CFM)
in nstgmnce of the gaming of this permit.
�V AIR HANDLING UNIT(OVER ID00)CFM)
Signatum of ApphcmVCmmm or Date EXHAUST HOOD(W/DUCU
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0110 BTU) Dam Receiplk
Will the applicanl or future building occupant store or handle harardous material
as defined by the Cupcnin.Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cade,Section 25512(e)1
❑Y 26. VENTILATION PAN(SINGLE RESID)
BOILER-COMP ISSUANCE DATE
Will air con ormorns a%re bundle!bycirme
nBay Area
Air orality Management t (JHP OR 100,000 BTU)
Insurancenet? air comaminmm as defined by Ne Bay Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distncp
❑Yes <Nm NEW RESIDENTIAL MECIL SQ.FT. sy,4 p
I have read the huurdous materials reqm
uircents under Chapter 695 of the F" A Po
California Health 6 Safety Coda Sections 25505.25533 and 25534. 1 understand that 6/
if the building dims not currently have a mmol,that it is an,rcsp.nsihilitymnmifythe ^ as U
cupant of the requirements which most be met prior to issuance of a Cenifc:te of
Occnpancy.A
Ow) Nnnzcd.genl IDore
TOTAL: 3 ISSUEfUB4`
OFFICE