25624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINONG- LE. RI A. PERMITNO.
.APPLICATION/PERMIT PLUMBING-MECHANICAL
WILDING DIVISION - BUILDING FRUJRCT IDENTIFICATION 25624
BU LIA GADDRFSS``: /� SANITARY NO. APPLICATIONSUBMTITALDATE
5/U O �� f/ UNIT#7APPLIANCM-RESIDENTIAL
LOT• Ce'k-44'
O S NAME: ONE: 'S NAME) LIC NO: — VOwl/ N/C CONTROLp
HITECOENG EER:CONTACT: PHONE: BUILDING PERMIT INFO
ELECTRIC PERMIT FEEBLDG ELECT P MECIIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION NCES-RESIDENTIAL LOB DESCRIPDON
paz I hereby affirm that l am licensed underprovinionsofChapter9(catmnencing with
�00,bE failIn 9 nd)e fact. on J of the Bulinus and Professions Cae,end my licenu is inSJ -
<� Lilrrreeand effect 200 AMPS L •Gz License Clnss Lic.pyDate Cuntmctnr 000 AMPS
ARCHITECTS DECLARATION SQ.PT.FLOOR AREA 5/SQ.FTIunderstand myplans shall heuud u public records1000 AMPS ELECTRICAL
Licensed ProfessionalOWNER-BUILDERDEC Contra ON L CIRCUIT/MISC.
K
O:U 1 hereby aftionn.(Se that I um exempt from the Contractors License Law co the
�+coI followwhichingmasoa.cmd,tocrutraw,ction 7031.5, sinus andve,demola Code:Any ,murneunty TEMP.METER OR POLE INST.
ON¢ Four t requires n eer is on cares the apo,improve,demolish,ar repair any swment
YC) that he iaimnancgaHotaqu,the
Neapplicant
er.ffor such Copermiuorile a Lioem La comment POWER DEVICES
10
Iy �Oz Nm he isncingwaed pmaction7he)offn isi n the Convectors Lice ase Laions(Chapter
2L�4OW 9that he is
Section70013) Division Sof lleBmuemptio .Ary,mu Cade) SWIMMINGPOOL ELECTRIC VALUATION
W❑y
orthat701.5 by wy.pplimand the PermitrNetsegedexeicamm.t.wil Flnalty of OUTLETS-SWITCHES-FIXTURES
a Y Section 9ffi i any applicant fora permit subjects Ne applicant m a civil penalty of
G nm oremNan five It dnllan($SW).
era'on'ropeny,ormyemptoyewwithwagoastheirsolecompematlon, NEW RESIDENTIAL CLEM _SQ.FT. STORIES O'YPECONSTRUC7OON
B: tll doth.work,and the stmctureisnot immrdedorofferedfersale(Su.9044,Business
d Professions Cade:The Contractors License Law does not apply to an owner of
property whobuildsorimprovesthercon,and whodms such workhimselforrhrough his OCCGROUP RES.UNITS
ownempinyecs,Provori prsuchimprovementsarenotyeandedmoffered fanwn If,
however ill have the Orden of ement i.sold a did one yeaofcompl a for heawncr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpou of
le.). QTY; PLUMBING PERMIT FEE APN
[1I,as owner ofthe property,am exclusively contracting with licensed contmton to OD ZONE
connuct the project(Sec.9044,Business and Professions Code:)The Contractors
License Lawdoesnntapplyloanownero(property whobuildsorimprovuthemn,end PERMIT ISSUANCE
who contracts for such projects with a contmtot(s)licemed pursuant tothesContracmr# GRAIN ALTER
- M&VENT WATER- EA
License Lew. 1 ( ) FEE SUMMARY
❑ I ern evempt under Sec. B @ P C for this reawn BACK FLOW PROTECT.DEVICE D
SANITARY Y N
Owntt Data DRAINS-FLOOR.ROOF.AREA.COND. RECEI #
WORKMAN COMPENSATION DECLARATION PTSCHOOLTAX YN
❑ I hereby afftm that[haveacenificateofcom ttoaelf-imum,oremnificateof FlXTURL•S-PER TRAP RECEIPT#
Worken'Cona,mation Insmancem.cmified copy thereof(So.3800,Lab C.)which PARK FEE Y N
coverra all employer's under this permit. GAS-EA.SYSTEM-I INC.40IffLETS �� RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseclma need not be completed iflne permit is fortune hundred dollars($100) SEWER-SANITARY-STORM EA.200rF. ENERGY FEE
or less)
I ceoy that pearnperformanceinmanner
so
for whish Niepemtito the talxhAdlkers' WATER HEATER WNENT/ELECIR
not employ any pcmn in any munnef so es to become subject to the Workers' PAID
Compemmim laws of California. Data WATER SYSTEM)1'REATING Date Recciptp
Q z Applicant
Z 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rA become subject to the Workers Compensation provision of the labor Code,you must
a , forthwith comply with such provision.or this permit shall be deemed revoked. BUILDING IEE
¢7 QSEISMIC FEE
CONSTRUCTION LENDING AGENCY
z 1 hereby affirm[hat here is a construction lending agency for Ne perfannana of ELECTRIC FEE
U p the work for which this permit is issued(Sec.3099,Civ.C.)
Lenders Name
U" Lenders Address QTY. - MECHANICAL PERMIT FEE PLUMBING FEE
GULL I certify that 1 have read Nis application end scare that the above information is '' MECHANICAL FEE
mored.I've mplywithallcity and county aNiulnces and sate laws relating to PERMIT ISSUANCE.
mildingco cti n,ndhembyaahariaerepmsenmtivesofthiscitytoentmupontM CONSTRUCTION TAX
U z above-me oned ropenyforinspecdonpurpaees. ALTP,RORADDTOMECH.
(We a to save,indemnify and kap City of Cupertino against
lkbilitiu, ents.costsand ay ammeegainst said City AIR HANDLING UNIT(TO 10,000 CFM)
in of the grnnti s
AIR HANDLING UNIT(OVER 10,000 CFM)
Sign rtof IicanUConuecmr to L%HAUST HOOD(WIDUCO PAID
HAZARDOUS MATERIALS DISCL RE HGTING UNIT(TO 100,000 BTU) Dau Receipt#
Will the applicant or foam building occupantsm rhandlehmudousmaudal HEATING UNIT(OVER 100,000 BTU) TOTAL:
es defirud M1y the Cupertino Municipal Cale,Chsptcr .I2,and the,eaIN and Safny
Cale,Section 255320)9 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will theapplicantorfoture buildingoveapaamuequipmenmrdevices wnichemit BOILER-COMP(311P OR 100,000 BTU) gg��
haaardmw air contaminants as defined by the Bay Area Air Quality Mans,nnem BOILER-COMP(OVER I00.00D BTU) 5"- A ' D
Dlsrda7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. T
Lbuildien,
read the brusendous Code,materiel.5505,25533a under 34.1 Chapter understand
of the OCT12
2
eoth A Safety Code,Sections 25505,2553)and 25534.1 undersand Chet ys
g does not comemly have a mnant,that it is my responsibility m notify the C�IY �I
the requirements which must he met primm Von..of a Cenificau of Vr1'Vrtl7thorized agent Oeu TOTAL: ISSUED BY:
OFFICE