25492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAI. �] 5 �I (J n
BUILDING DIVISION BUILDING PROJECTIDF.NPIFICATION L J 4 J G
BUILDING ADDRESS: �o SY s S�FARYO. AIITLILICA'nON SUBMITTAL DA TE
O J CI'74 ORRJUNIT. fll� LOT If
LIC NO OWNERS N ME PHONE: NTRATR'S („
JME
Q/ N/C CONTROL#
• A HITECf/ENGINEFR: LIC NO: DDRFSS: bb
0 6 CA.41 0 9 s ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ZZZA(!�
BLDG ELECT' PLUMB MECH
� P[RMI1'ISSUANCE El El ElLICENSED CO CTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz Ihembyaffirthot
nl am licensed under provisim,t.fCTapmr9(commercing with
MUCO1=. Section]UUIBof Divi,km 3ufthe Busine, inlProfessions Code,andmy license is in PANELS Y
FWdu fan fareeand effirt o O
F Z<c. 1-iccnx lass l�'A Ur,If �q 11 UPT02DBAMPS
m=y :-)am FECTS Dr Ca 2(11-IIXIII AMPS
7ONZ A CIII'IECTS DI3CLARA'TION OVER Ithp AMPS F R A SR� AREA $/SQ.FT.
O Z—O I understand my plans shall be used as public records. \,
P,4L j SIGNSELECfRICAL —• II- v
CQ 7,, LiansM Pmfarsional ' r—..
a'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIS �1,=
KOc. 1 wish,affirm that I cm exempt from the Comoss m's License Low for the
�3Ovf—i following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F'�yJ which reclaims.permit err cm.etmct,abet,improve,demolish,or repair any soumarc
>� prior co its c,mmcc,alsorequms theapplicam for,uch .it,.file.signedsmtemrm POWER DEVICES 16
W K O p that he is licensed pursuing to the provisions of the Convectors License Law(Chapter
ay 9Rmorwrcing with Section 7")of Division 3 of the Business end Professions Cede SWIMMING POOL ELECTRIC
xO ) VALUATION
W_m arthim tion70 c.5 by an applimand the ntforaPermitonhe tsduedexemptioo. civil loultyof OUTLETS-SWITCHES-Fl%TURES 9oo
F'L¢ an,rom)Bhm5iv anydollaE$50rmitsubject the epplicanno.civil penalty of
not mom th. erofthedr ny,t)rmyem). NEW RESIDENTIAL CLEM —SO,FT.
a_o ❑ I,aso ork,oDhep lamea nr myemployerminfemd to'saleiSec.compensating STORIES TYPF.CONSTRUCTION
3°—° will Jothewons Code:
no Commentsint is License
La dos sale
1.out Business
mJ Professions Calc:The Commnor's License Lew Jces oat apply co en owner of
proprny who bu ilds or improves t hereon,and who docs such work hi,.self or through his
own employees,powidedmat such lmprovememsmenot mendedoreffered l'orsale.If. OCC.GRWP RBS.UNITS
however.the building or improvement is sold within one year ofeempletion,the owner- TOTAL:
builder will have the burden of proving that he did tot build or improve for purpose of
TOTAL-
sale.).
❑ Las owner ofilm property,am exclusively contracting with licemedamtruc,.rsto QTY. PLUMBING PERMIT FEE FLOOD ZONE ppN
tmtecc the project(Sec.7044,Business and Professions Cafe:)The Contractors
License law does.,.apply Loan ownerofpropeny who builds in improvesdirmon,and PERMIT ISSUANCE
who contracts forsuch projects with a contractors)licensed pursuant to the Contractor's ALTER- WATER(EA)License Law. DRAIN&VENT- FEE SUMMARY
❑ I am escmpt under Sec. ,B&P C for oris reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y_N
• Owner Dam DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT is
WORKMAN COMPENSATION DECLARA'HON SCHOOLTAX Y N
❑ (hemby vffirn the lhaveac<nificam of consent to self-insue,ora certificate of Fl%TURES-PER TRAP RF.CF,IPT#
Wnrkers'Cnmpensacion lnsurunce nracenified copy thereof(Sec.JS00,lab CJ whicM1 PARK FEE YN
enve"all employge'rynJek4hisI"W' 3 8 9 GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# DD 44 L 77
Company BUILDING DIVISION FEES
El Certified GAS-EA.SYSTEM-OVER 4(EA)
rtified copy is hereby famished. PLANCHECK FEE
❑ Cenifird copy is EIM with he city im,cedfan division. GRFASMNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ME
INSURANCE
(This section need not be completed ifthe permit is onion,hundred dollars($100) SEWER-SANITARY-STORM FA.203FT.
or less) ENERGY FEE
I certify that in performanceofthe work for which this permit is issued,1A.11 WATER HEATER W/VENT/ELECTR
not employ any person in any manners t as to became subject to the Workers' PAID
z Compenemmulawsof Califomiv. DateWATER SYSTEM(IREATING
A,firma Dam Receipt If
Q
z 0 NOTICE TO APPLICANT:IG after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.F, TOTAL:
1"' ` beenowsubjectto the Worker's Compensation provisions of the Labor Code,you must
> forthwith comply with.such provisions or this permit shall be deemed revoked. BUILDING FEE
VJ 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the perfomance of 1
V 0 the work for which this permit is issued(Sec.RAG.Civ.C.) =O."CFM)
TOTAL: ELECTRIC FEE
Lend.-Name
00 U Lender,Address QTY. NICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is
FCL, cored. I ager m comply withall city and coamyordinances and scam laws elating co E MECHANICAL FEE
_ building comeruccion,and hereby awhorime representatives of Nis city to enter upon the
U z above-mentioned property,for inspection purposes MECH. CONSTRUCf10NTAX
(We)agree to save,indemnify and keep harMess the City of Cupertino against
linbilitia.judgmens.costs and expenses which may in any way accrue against said City UNIT O."CCFMIquence of tl�grant 9 permit.y �+�7 � NIT(OVER 10,"CFM)
...000 / is D ..1//
Sign' rc I'Applicant�/Coio tar Dam EXHAUST HOOD(W/DUCq
PAID
HAPARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Raeipt p
Will the applicant oro ture Municipal
de,Cap stoat or andhandleIn hlydrlh .material
C Jr.Sed io the 32m)?no Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER Ifp,tAp BTU) TOTAL
Calc,Section 25532(e)^
❑Yes 0N VENTILATION FAN(SINGLE RFSID)
BOILER-COMP ^ISSUANCE DATE
Will tai,contaminants
is as defined by the
tay Area mir Quality
Man gM1 ant (3IIP OR IOO,IXp BTU) r A I D
•L
us air nmaminams as defined by thr Bay Area Air Quality Manegemem BOILER-COME(OVER IOQOW BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. AUG P-6
as
e read the hmmdons materials requirements under Chapter 6.95 of the .1993
Health&Safety Code.Sections 25505,25533 end 25534.1 understand mat
ing does not currently have a tenant,that it is my responsibility to notify the CITY Lit
1#�renr
f tcy.uthorized agent Dan. TOTAL:
ISSUED BY:
OFFTCE-