25412 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B T�4Ir-F]LEuTR AI' PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C /I f�
BUILDING PROJECT IDENTIFICATION 5 4 G
BUILDING ADDRESS: /_/ /./���'',// 1T/ SANITARY NO. APPLICA'HON SUBMHTAL DATI
2 l! / NIT# r LOT P Z�
PER NAME: PHONE: CrO 5 CNO: N- CONTROL#
i o P
�ARCHITECT/E14GINEIiR: LIC NO: Dl)Rf$ �-t_ - 1:1`_�LC`lll
CONTACT: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
2 6�� BLDG ELECT PLUMB MECH
DvlgdPERMIT ISSUANCE El 1:1 ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
awz Iherebyaffirm that l am licenseduadefprovisionsuf Chaper9(commencingwith n
4100 Section]WO)of Division 3m`the Business and Professions Calc,and my bran.is in PANELS
FywUt full forec and effect rlalf/!
FZ41 License Class Lic.p UP TO AMPS /
wQy Date Choose 201-I01M)AMPS
J Q'z ARCHITECTS DECLARATION 5 .ILO R $/SQ.FT.
0 Z_ 1 undcrswnd my plans shall be used d public records. OVER IOW AMPS
`y F 41 SIGNS ELECTRICAL
KKK Y ; Licensed Professional
yrd< OWNER-BUILDER DECLARATION SPECIAL CLRCUITSUSC,
aF 1 hereby Alirm that I am exempt from the Contractor's License Law for the
w 3 0,m following mason.(Section 7031.5,Beams.and Pro&.shore Codc:Any city or county TEMP.METER OR POLE INST.
�C'j which requires a pemtit to conswet alter,improve,demolish,or repair any structure
to or
prior an itsissuance,also mgaires the applicant for such pemduo file a signed statement POWER DEVICES
G0 that he is licensed pursuant to the Provisions of the Contractor License Law(Chapter
Xe9(cmmmcncing with Section]U00)ol Division Jofdte Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
WM, or that he is exempt therefrom and the basis forthe alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
� ¢
Section 7031.5 by any apphcam for a#ream(subjects the applicant to a civil penalty of
f2 not more than five hundred dollars($5W).
zF. ElI,asownerofthcprnparty,nrmyemployeeswiNwugesusthcirsolecompens.tion, NEW RESIDENTIAL ELECIR SQ.FT. S BIAS TYPE CONSTRUCTION
x322 willdothe work,mdthestruaure is.1 mandetlomffcred facile(See.]Oa4,Business `y
and Professions Code:The Contractors License Law does not apply to an owner of
pmpeny who buildsmimproves thirmc m,and whodues such work himulforthrough his
ownemployces.provided Nat such improvemeres are mairmodeloroffered forsale.if, OCC.GROUP RES.UNIT'S
however,the buddingor improvement is sold within one yearofmnmpldion,theowaer- TOTAL:
builder will have the burden of proving that he did not build or improve fm puryou of
❑ Las uwnendthe propcnY.emeadusively wnhaning with licensed contractors to QTY. PLUMBING PERMIT PEE FLWDZONE qpN
construct the project(Sec.701q Business and Professions C(Ac:)The Contractor's ' pERMII'ISSUANCE, r
License Luwdees not apply to an ownerofproperty whobuildsor improves thersamantl
whocontmet for such pmjats with acommnot(s)licensed pursuant to the Cardiac a
Liansc Law. ALTER.DRAINffi VFAVT-WATCR(IiA) FEE SUMMARY
m
❑ 1 aexemanec.
exempt tler S ,B&P C for this reason BACK FLOW PROTECT.DEVICE, OIIT sIOFF.8
SANITARY YN
Owner Dam - RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLUOR,ROOF,AREA,COND,
SCHOOL TAX Y N
❑ ers'Co affirmthntlhaveacora reamofconumerrof(insure,or Lob C.)which FIXTURES-PER TRAP �J RECELPTp
Workeri Cmmpensationlnsutanceoracertificd ropy thermf(Sec.3800.1ab C.)which PARK FEE YN
n all employee's unde,dre pemtit GAS-G.SYSTEM-1 INC.4 OUTLET'S RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Ceniliede.pyishearbyfumished.
❑ Cenified copy is filed with the city inspection division. GRF.ASf71NDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplcted ifthe permit is fm one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I candy that in the performance ofthe work for which this permit is issued.)shall WATER HEATER WIVENT/ELECI'R
not employ any person in any men as m become subject m the Writer% PAID
O z Compensation Lawsof Califuniia. Date s0 WATER SYSTEM[TRFATING Date Rettipt#
Applicant
z 0 NOTICE TO APPLICANT:ILuftcrmaking this Ccrlficule of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rr ^ become subject o the Workers Compensation Provisions of the Labor Cade,you must
aforthwith comply with such provisions or this permit shall the deemed revoked. BUILDING FEE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 herchy affirm that there is a construction lending agency for the performance of
V O the work for which this pemtit is issued(Sec.3007,Civ.C.) TOTAL:TIT-071—
_0 ELECTRIC FEE
Lenders Name
ULendernnddrcas QTY. MECHANICAL PERMIT FF,F. PLUMBING FIE
1 cenily agree to L have read this application and stem that the above information is
OW.. building canerto comply and"ith eeby Au sand county ordinances osand iscity neatlaws enter upon
PERMIT ISSUANCE MECHANICAL.FEE
U building cons
truction. hcrcbyae[ion
rpmus.etives ofNiscitymrnter upon Ne
V z neJpsave.ifor ndemnify
ind purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
to save,indemnify and kap M1armless the City of Copcnino against
ms,costs and whichmayintai ac crueagaiestsuidCity AIR HANDLING UNIT(TO 10,080 CFM)
in so fNiw mit.
ALR HANDLING,UNIT(OVER 10,(X10 CFM)
nature of pplicanVComrutor Dam EXHAUST HWD(WDUCT) PAID12 4-\S
IIA% RWUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Doc Reccipta
Will the applicant or future building occupant store sur handle hazardous material
as defined by the Cupenino Municipal Code.Chapter 9,Q.and the Health mat Safety HEATING UNIT(OVER 1100.000 BTU) TOTAL:
Code,Section 25532(.)1
❑Yes ❑No VENTILATION FAN(SINGLE RESLD) L�
BOILER-COMP(3HP OR 1 00.000 BTU ISSUANCE DATE
Will Tan aconturntorfu as,refined
by the Bay
Managemees which nt ) pp
hazvdous air conmminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 1 00,000 BTU) P M D
DisoicIT
❑Ya ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have mad the hazardous materials requirements under Chapter 6.95 of me DEC — 9 1993
Califomia Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a tenant,that it is my ms,mibiiny m notify th<
occupant of the requirements which most be met pdons.issuance of a Crnificme of Cl I r to v V r I:OT 1114 V
acapaary.
Owner to authonzed agent Date TOTAL: ISSUED BY:�
OFF /