25411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
PERMIT NO. 25411
CITY OF CUPEPLUMBING.MECHANICAL
BUILDING DIVISION
swN APPLICATION/PERMIT NUILIIINGPROJELTIDP.NI'IFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
RI'II^LDIING DDRIi$S/,y-�s 1z/�
I �J TTM D Its a LOT#
OWN RSNA II: � PHONN: _ NTRACTOR'S NAME: .CND: NIC CON TROL#
R HI CT/ENGINEER: LICNO: ,LI, 1 El
I :ONTACT: PHONE: IBJ V BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT' PL�Up�I]B M ICH
V40 g 'PERMIT ISSUANCE+.. ❑ ❑ I!�-� ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
9mZ) Iherebyeffnm tool l am lieemedunder provisionaofChapter9(commencingwith
00 Section]000)ofDivision 3af the Rosiness and Profession Code,and myliuneis in PANELS of a�=afy I P� Gl
K full force and effect. "/a
s6s..Zu� License Class Liu,.# IIP T0200 AMP$ 4
tnjy Dam Convecmr 261-1(XIOAMP$ SQ.FT.FLOOR AREA SISQ, .
Z~O vyi Z, ARCHrMCPS DECLARATION OVER 1000 AMPS
0.y 1 understand my Plans shat]m used as public records.
w SIGNS ELECTRICAL
F4=N f j Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
°�OaU 1 hereby vffi.that 1 vin exempt from the Contractor's License Law for the
W 3 LL y fallowing mason,(Section 7031.5,Business end Professions Cade:Any city orcounty TEMP,METER OR POLE MST.
LLr 0; which requires a permit m comic,elm,,improve,demolish,ar repair any atsutturt
rionoasis,imix,alsorox,irestbeapp]icontfor curb pmmO.filettai,nedmmment POWER DEVICES
Co that he is licensed pursuant to the provisions of the Corrosion's Ucebx law(Chapter
d
is.o 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC p ] V N
y _w or that he is exempttherefrom and the basis for the alleged exemption.Anyvioiadonof OUTLETS-SWITCHES-FIXTURES T
IZ F Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of a .�
$ not more than five hundred dollars($Soo). NEW RESIDENTIAL ELELTR _SQ.PT.
Co ❑ I,asownerofthepmo rty,ormyemployeeswiNwugesasibeirsolecompensation, R TYP CONSTRUCTION
Ed willdothe wmk,amd thesnucture is not imendedoroffered formic(Sm.]044,Business
and Professions Code:The Contractors License Law don nor apply m oo owner of
property whobuildsmimproves thercon,and whodoes such work himselforthrough his _
employees.prnvidedthm such improvememsme not inmndedoroffered(ornate.IL - OCC GROUP RES.UNITS
Mweser,the buiMiogorimprovemem is sold within one ymoofwarpletion,theownn- TOTAL:
builder will have the burden of proving thin he did bar build or improve for purpose of
tale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE "N❑ I.asownerofthepmp Ay,amexetusivelycontrmtingwithlicenxdcont wmto
comma,the project(Sw.9014,Business and Professions Code:)The Convectors ,`
LicenseLuw dims not apply to an owner afpropmY who builds.,impmo rs Ibemon,anPERMIT ISSUANCE d tg--OD
whocontructs forsuch projecm withacommucmr(s)licensed pursuant mthe Convactor's ALTER-DRAIN&VENT-WATERER
umms,Law. LEA) FEE SUMMARY
�� ❑ I am exempt under Sec. ,B&P C Aur this masonES
BACK FLOW PROTECT'.DEVICE SIDE E
^-✓ SANITARY Y_N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercbyaffirtn lM1arlhaveecenifiwu of conenun self-insure,ora cenifcam of FIXTURES-PER TRAP RECEIPT#
Worker'Compensation insuraneeoracenificd copy]here.f(Sec.3800,Lab CJ wM1ich PARK FEE Y N
ars ell emDloya's under this permit GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT M
Policy# BUILDING DIVISION FEES
Company GAS-E.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenifiedcapyisherebyfumimM.
❑ Cenifled copy is filed with the city inspection division, GREASEWNDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section mednm be completed ifthe permit is forone hundred dollars($100) SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
or lesaJ
I ccnify that in the ptrfanumneeof the work for which thispumit is issued,l shall WATER HEATER W/VENT/ELECIR
wt employ any person in any m as m become subject to the Workers' PAID
Compansati.nlwwsof Califocro.nDme so WATERSYS9'ENIfIll TING Dam Receipt#
OZ Applicant
y z NOTICE,TO APPLICANT:if,after making this Cenif¢era of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
Became subject to the Workers Compensation provision of the Labor Code,you must
afoMwith comply with such provisions m this permit shall be deemed resulted. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
UO
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
Lenders Address QTY. MECHANICAL PERMIT FGIi PLUMBING FEE t bn
LTJ 1 eengy that I have reed this city
aind county
and rune that the above inflaws
relation is MECHANICAL FEE
nmrea.lagme to comply with all city vmM county oMinences and slate laws relatingm PERMIT ISSUANCE
04
building construction,mdhemby authorize representatives of Nis city tamer upon the CONSTRUCTIONTAX
U z, above- edpropeny fnr inspection purposes. ALTER OR ADD TO MCCIi.
(We7 agrx m save,indemnify and kmp handless the City of Cupertino against
in
nu,cash andexpe ymany way accrue against said City ATR HANDLING UNIT(1-0MINE CFM)
in coiue a of toe inga nnitc
m \ n AIR HANDLING UNIT(OVER 10.050 CFM) �a )
gnatme of AppmaMm
Cmdrror m EXHAUST HOOD(W/DUCT) PAID I Z (•,t�
I IAZAROOUS MATERIALS DISCLOSURE HEA'TING UNIT(TO 101,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle haando rs material
u definedby the Culxnino Municipal Code.Chapter A 12,and the Health and Safety HEATING UNIT(OVER 100.000 PTU) TOTAL:
Code.Section 25532(a)] VENTILATION PAN(SINGLE RPSID)
❑Yea ❑No
ISSUANCE DATE
Will the applicvm orfuwrcbuilAingoccupam vuequipmentnrdevicea which emit BOILER-COMP(3HPOR 100,00(1 BTlJ)
hazardnuv air conuminmds as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A D
Dktricti
❑Yea ❑No NEW RESIDENTIAL MECH. SQ,FT.
1 have read the hazardous materials mquimments under Chapter 6.95 of the DEC - 9190
w� a
California Health&Safety Code,Sections 25505,25533 and 25534.I understood that
if the building does not currently have amoank that it is my responsibility to notify the G1IY Vf vVfQf[IINU
occupant of the requirements which must be met prior to issuance of a Ceni icate of _ V
Occupancy.
Owmroraulhorizedagcnt Dem TOTAL: ISSUED BY�JA��W�V Y•