25290 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[BUILDING
TY OF CUPER'1'INO R U,JUNi O-F.LLUIIJ ICAL PERMIT NO.
APPLICATION/PERMIT PLUMHINC-MECIIANICAI. 5/�(�a
BUILDING DIVISION BUILDING PROJRCT IDENTIFICATION J G J
1,^ADDRBSS: / �aLSANITARY NO. APRICATIONSUBMTITALDATI
V /17 Ce we 1 UNIT# LOT) `�/q���(/AME: PHONE: TRACTOR'S NAM LIC NO: NIC CONTROL#
D�- L120,n
RCHITECTIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MGC
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
mwv I hereby affirm that l am licensed under pmvisionsofChapter9(commencingwi[h JOB DESCRIPTION
1-00 fulltlbreenodcffD 3oftha Business an ofejionsCWg are is in PANELS
UPT0200 AMPS
La,G m Licenx Class Lic.#
F=d Dale Commnar 201-11100 AMPS G �
/py! ARCHITECTS DECLARATION OVER 1000 AMPS ITL A FT.
O z—a I unders d ry plans shall be used m public records.
r y(=W SIGNS ELECTRICAL
� Licensed Professional ^�,I IIffI (/)I �f✓�
�C'W< OWNER-BUILDER DECLARATION SPF,CIAL CIRCUIT/MISC. / ✓ L\✓'J 11 T
X1 hereby affirm that I am eaempr from the Contractor's License Law for the
W�Qy following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INVE
W 5 which requims a Permit to construct.alter.improve.demolish,or repair any structureE
C�>7� pdormitsissuance,alsam,moestheapplicant far such pemritm file usignedsmtemem POWER DEVICES
WC Ci that he is licensed pursuant to the Provisions of the Contractor's Licenw Law(Chapter
Qi. toK 9(commencing with Section7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
x4 VALUATION
W—My or that he is exempt friction and the basisfor the alleged exemption.Any violation of OUTLETS-SWITCHES-
J—,Q Section 703 IS by any appli<untforn permit subjects the apPlicanuoncivil pewlty of FIXTURES
not more[ham five hundred dollars(5500).
y�'FQ ❑ I,uowncrnr[hcpro NEW RESIDENTIALELECTB
W em peny,ormy employceswith wages axtheicsolecompen.arisen, SFORIES TYPE CONSTRUCTIOD
a3— will do the work.andthe swcwre is not immndcaoroffered forsale(Sec.]044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself,),,hrough his
employecs.pmvided thasuchimprovemcros are not intended orof&red for sale.l[ OCC.GROUP RIS.UNITS
however,theavet a burden of proving that
he id noneyear ofcnmove for surpsomr- I
builder will have the burden of proving rhes he did not build or improve for purpose of
rate.).
❑ Las the profit(Sec. 0,14,Business
with licensed Contractor's
QTY. PLUMBING PERMIT PEE FhOOD ZONE ANN
License she oes not(Sec.?1144.Business and y bobiona arimp The emmar.a d
License not appjects with
a compactors)whobad parsrimpto the Thereon,and PERMIT ISSUANCE
whose tractsUse.forsuch projects wLhuttmveomr(s)IieenacJ pursuantmihe Convuc[or's ALTER-DRAIN&VENT-WATERER
License Law. ( ) FEE SUMMARY
❑ I am emmpt under Sec. ,B&P C for this reason BACK PLOW PRO'TECP.DEVICE 01 IT71DIi IDBS
SANITARY YN
Owner Data DRAINS-FLOOR,ROOF,AREA•COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have ucenifeem orconsem mself-insure,or iturnifirateofFIXTURES-PERTRAP RECF,IPT#
Worker'CnmP mtionlmumnceoracmiri mp"thermf(Sec.380o.UbC.)which I PARK FEE Y N
covers all employee's under this permit. RECEIPT#
Par,# CAS-FA.SYSTEM-]INC.4 0UTLIiTS
BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER4(G)
0 Certany CenifiM copy is hereby famished, PLANCHFCK FEE
❑ Certified copy is fled with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING WE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Brie Permit is forone hundred dollars(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY
ser ass.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER WNENT/F.I,ECTR
of employ any person in any manner so as to become subject to the Workers' PAID
z Compensation laws of California. Date WATER SYSTEWFREATING Data Receipt#
Applicant
z O NOTICE TO APPLICANT:IL after making this Cacti ficata of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
pbecome subject to the Worker's Compensation provisions of the labor Code.you most
7 forthwith comply with such pmvisiom or this person shall be seemed revoked. BUILDING FEE
y
CONSTRUCTION L ENDING AGENCY SEISMIC FEE
1 hereby affirm that hem is a construction lending agency for the performance of
U O the work for which this Permit is issued(Sec 3099,Civ.C) 'AL: ELECTRIC FEE
Lender's Name
pU Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 eenify tem 1 have read this aPPlieation and state that the above information Is
4 correct, lagme to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICALFEE
_ V) buildingconswceon,and hereby authorise representatives ofthis city to enmrupon the
U z ahovcnamio crtyforimIsaimnpurposs. ALTER OR ADDTO MECH. CONSTRUCTION TAX
(We) Tae toe e,indemnify mrd keep hmnlesa Ciry of Cupertino egainss
liabilities udgme s sts anJ expenses which may
y yaceme againss sail City AIR HANDLING UNIT(TO 10,!1(10 CPM)
mnPeq n granting of this permit.
n r
'A,,-r7
AIR HANDLING UNIT(OVER IO,IXq CFM)
S' nawrc of Applican C tour D'aI¢L�f//' EXHAUST HOOD(W/DUCT)
PAID
AZ LOUS MATERIALS DISCLOS I HEATING UNIT(TO I ,),hili 1fTD) Dute Receipt M
Wiilthcappl' antor wm builtling occupant store or handle hazardom mamriW
mdefinedbythc pectic unicipal Cade,Chapter 9.12,and the Hcahh and Safety HEATING UNIT JOVER 100,000 BTU)
GWq Section 2553 (a)Y
❑Yes ❑ o VENTILATIONFAN(SINGLE RESID)
BOILER-COMP(3HP OR 10o con
BTU) ISSUANCE DATE
W ill theoprrvion orl'uturehuildmit cc afeart useeyuileari ordevices whichemit
hazardous nu contaminants as defined by the Bay Area Air Quality Management BOILER- i"�
District? COMP(OVIiR IW,000 BTU) p '
❑Yu ❑No NEW RESIDENTIAL MECH. SQ.ET. O
1 have read the hazardous materials ca mo mems under Chapter fi 95 of the V C
California health&Safety Code,Sections 25505.25533 and 25534. I understand thatI`s/ U ���
if the building does not currently have a tenant,that it is my responsibility to notify the V
occupant of the reyuirrince s which most be met prior to issuance off Cenificate of h
Occupancy. Gtr ti
owner,or amhon.M agent Data
T TA ISSUED
OFFICE