25595 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHB.IHN -brI.11 RICA], PERMIT NO.
APPLICATION/PERMIT
PLUMBING-MF.CHANI2 C C 9 C
BUILDING DIVISION BUILDING PROJ4:CI'IDN:NTIFICFICA'TR)N J J J J
BUILDING ADDRESS: w�nyss�aa CC'' SANITARY NO, APPLICATION SUBMITTAL DATE,
�r// '9ZIe-A ' UNIT#LR A p) / LOT Or Ir�JJ l ��1n ��l
OW HU6& SYlwz,* PHONE / 1 CO /TN RTD�[9 7IC LI V�.D11 /����
C. NA] CONTROL p
RCHITECT/EIGINEER: LIC NO: ADDRESS: ❑
103M
'ONTAa': PHONE: f QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
D ufr{,L BLDG ELECT LPLUMB MECH J9 T PERMIT ISSUANCE �� 1SlI El E]
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
owz, I hbin ti
creyafficrOdet l seensedunderprovisio9
nsidCTaptcr (c'mmcncing with
W00 Section 700(1 of Division 3 of the Business and Professions Cade,and my license is in PANES Sit(
'
K W full force and e[!t. Jit(
<�ty License Class a Lic. UPT02WAMPS -
h ti Date Cr draanr 201.1000 AMPS
F m Z ARCHITECTU S DECLARATION SQ.FT.FLOOR AREA, $/SQ.FT.
ZOm IunJnrrtanJm Ins shall blic records. OV IBM AMPS
OZ'-'o any per
Fj
IGNS F1.ECTRICAI.
Licensed Professional
Kaa OWNER-BUILDER DECLARATION PECIAL CIRCUIT/MISC.
KOaF I hereby affirm that 1 am exempt from the Contractor's License law for the
m3aya h0lnwing reasov.(SnOimn]03 L5,Business and Professions Code:Any city ormwny TEMP.METER OR POLE MST.
F u'�.] which mluires a permit to construe,alter,improve,demolish,or repair any sructure
fsD>� prior.its issuance,also returner the applicant for such permit to rite a signed statement POWER DEVICES
yecjK�O thin he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a Y 9(c'mmenein with Section TN10 of 3 of the Business and Profession Code SWIMMING POOL ELECTRIC
ce g`vi )o ) VALUATION
ty_y onhat he is exempnherefrom and the Innis for thc"lleged exemption.Any violation of OUTLETS-SWITCHES-FUCIlIRES
L:•z Section 7031.5 by any applicant for a permit subjects the applicant to a civilpmalty of
nomore ore than five hundred dollars($500),
Cis- ❑ I.asownoroftM1c r NEW RESIDENTIALELECf¢ _SQ.FT.
pmpe y.ormyemployas with wegesntheirsolecompena0on. STORIES TYPE CONS'fRUCI'lON
a3°= will dothewons ande The,Contractor's
License Law
apply
to an
aro Professions Code:The Cont a feaw License Lew does not apply to an owner of
own emy whob.provi improves thercogwdwhod«sst inane k himulror through his
err,thees.p building
orided thatsuer impmvemcrosartne ewofea'ffeed fursathe o owner-
builder
OCC GROUP RES.UNIIs
however,the builJing urden of pment is sold within one year of completion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of
sale.). TY. PLUMBING PERMIT
❑ l,as the pmj ct(Se pe 0,14.Business
Professions
Q FEE HOOD ZONG
ycon gwiN licenxd c'nva<tors to APN
Licconense the project(Sec. aro Business and Profession Code:)The thereon,and
License Lawd'esnotapply.am'wnerofpropeny who
accUmnnumn.du the.c,.es PERMIT ISSUANCE ; a
who
ence Law.Eunuch projects witM1aconoac.r(s)licensed pursuanLL'the Conunnnr> ALTER- WATER .A) - r
' License Law. DRAIN � KE SUMMARY
❑ 1 em exempt under Scc. ,B&P C for this maven BACK FLOW PROTECT.DEVIC17 - ( �� AN 'A OUTSIDE FL
¢S N_
Owner Date DRAINS-FLOOR.ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION li YN
Wo llfcocn'C Nnsati ninsu ceoruEcniried nythe sf(Scsure.aaab C.)am of
FlXl'URES-PER TRAP ECPIPT#
Workers'Cmmpenaemonlnuhis pro certified copy.eremf(Sec,3800,Lab C.)which T; N
coven all employ«sunder this pertnit. GAS-U.SYSTEM-1 INC.4 OUTLETS RECEIPT#
1 obey# BUILDING DIVISION FEES
❑
[I CCnrynifed copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is fled with the city inspection division. GREASMNUUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action neat not be completed ifthe permit is feature hundred dollars($103) SEWER-SANITARY-SI'ORMEA.2WP1'. ENERGY FEE
or less.)
I cenify that in the performance ofncc work for which this permit is issued.l shell WATER HEATER W/VFNT/ELECI'R
not employ any person in any manner so as to become subject to the Workers" PAID
z Cumpenationlawsof California. Date WATER SYSTEMOREATING
Applicant Dale Receiprp
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENT IAL PLMIL SQ.PT. TOTAL:
F-' 4 become subject to the Workers Compensation previsions of the Labor Code.you must
� ; forthwith comply with such provision or this permit shall be dermed revoked. BUILDING FEE _
26 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE Ja
Z I hereby affirm that there is a construction lending agency for the performance of
U O the work far which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC IEE
Icactex Name
OU Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
re
W 1 certify that 1 have ad this appliewimn and sone that the above information is
F-' cancer rral lagreemcomply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MF.CItANICAL FEE
rn building construction,and hereby auNonscapresentatives ofthiscity to enter upon the
U z above-mentioned property fur1ndiser'n pwJswa,. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(we)agree..save,indemnify and keep hwmless the City of Cantedou against
Iiabiliticajudgmems.cost'and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
n
i CO(the greartur pent'
/ �s /j/J _ 9 AIR HANDLING UNIT(OVER IO,IXIO CFM)
Signature of phc '"towns' Date EXHAUST HOOD(W/DUCT)
PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTI) Dam Receipt#
Will rhea licant'r fumfe building occupant score of handle baurdmus mamrial
n defned by the Cupertino Municipal Code,Chirpier 9.12,and the Health and Salbty HEATING UNIT(OVER 1100.00d BTU) T
Cale,Section 25532(a)T
11 Yes ❑No VENTILATION FAN(SINGLE RESID)
Was air
applicantalavers defirrng by thenteraA Area
Air Quality
ceswhichemit
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
Mous air contaminants as defined by the Bay Asa Air Quoliry Munagcment BOILER- Rf r, 1 1)
isWcfl COMP(OVER 1W,000 BTU) 1,� q
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the h Safety
Craft.
ructions 5505iremavts ander Cbapur understand
of the SEP 28
California I lead.s Safcty Cale.Sections 25505,25533 and 25534.1 understand tthe 188ae
if the building does not currently have tenant,that it is myresponsibilitymnotify the JyV�f
occupant of the ca airemwnts which must it,'net prior m isxuance of a Cedificate of �11-Y OF
txudemey. 'r Ilyl`y,
Owner or au@'nxJ agent Dam 'TOTAL: (, J
ISSUED BY:
OFFIC