25836 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull.DINU-1?LF. '1'R]CAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 8 3 E
BUILDING DIVISION BUILDING PROJECT[DENT IF•ICATION
BUILDING
AADDRESS: SANITARY NO. APPLICATIONSUBMDTALDATI
90 QINK �Y .I/r4 Usi LOT# IZ
UWN YRS NAME: PHONE: CO A 'S NAME,: LIC NO:
,_,/ N/C CON"T ROL#
#lL' Sf.l- 773-710 J Pv\ G, / to Sle, o { 4z
•rCONNIAcr
'/ENGINEER: LIC NO: ADDRESS: ❑
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FGEBLDG ELECT PLUMB MECIIPERMIT ISSUANCE o
LICENSED CON'FRAC'1'OR'S DECLARATION APPLIANCES-RESIDENTIAL
ereM1 ffirm that l am licensed under fChu t 9 c mmencin JOB DESCRIPTIOpayyu pmProfessi par ad gwitht+t007da11 of Divlsionlof the Business and Professions Codc.and mylicense is in PgNEIS
V and effect. S �•NyQyLi
LimC�l,sa�=ContrS (� V 201-II"AMPS 1
,DyZ --F��—ARCHITECT'S DECDGL33 ppI'tA'f10N OVER Who AMPS SQ.IT.FLOOR AREA $/SQ.IT.
p%�,0 1 undersand my plans shall he used as public records.
1=.=FSIGNS ELECTRICAL
S Y,�j Licensed Professional
�y WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
LU
xg1 hereby uHom that I am exempt from the Contractor's License Law Boothe
Fr following re..oa(Scainn 00]15.Business and Pmfexnions Cade:Any city or county TEMP.METER OR POLE INST. II .I se`s
I_n.0¢, which requires a Permit to construct,alter,improve,demolish,or repair any structure
55IJ _
EE 7 prior to it, requires theapplicantforatub pe.iuo filea.ignedstatement POWER DEVICES "-- l/ � 1
m crcK p thin u
he is licensed pursuano the provisions of the Contractorrnu
Contractors Li< Law(Chapter fav II
p•X.E 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC '� V UATION
WM, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS -FIXTURE$
I,Z� Section 7031.5 by say applicant for a permit subjects the applicanuo a civil penalty of DATE
t mom than Eve hundred dollars($500).
uai m ❑ I.mowneroftheproperty,ormyemployecswlthwagesastheirsolecompensation, NEW RESIDENTIAL ELECTR SQ.IT. 59'ORIES TYPECONSTRUCDOD
y3_ will do the work,and the structure is not interalmoroffeted farsale(Sed.704Q Business
and Pmfiv,um,Code:'Rre Contraam's License Law docs not apply m an owner of
property who builds or improves thereon,and who does such work himself-through his
own employees,provided that such improvements am nor intended or offered for sale.If, OCC.GROUP RES.UNITS
however,the buildingar improvement issuld within one yearofcomplction,the owner- TOTAL:
builder will have the burden ofpmving thin he did not build or improve for purpose of
sale.).
❑ I,as ownernfthepropeny,ate exclusively convaming with licenutl contractors to QTY. PLUMBING PERMIT FEE FLOOD"LONE gpry
om.muct the project(Sm.7044.Busimexs and Professions Cade)The Conoamor'.
License lnwdoes not epplyto an owncrofpropeny whobuildsorimproves thereon,and PERMIT ISSUANCE
whocommeb for such projects with aconissior(s)liceased pursuanuo the Contractor's AI ITR-DRAIN&VENT'-WATER
License Law. (EA) FEE SUMMARY
❑ 1 in.exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date• HI
DRAINS-PLOOR,RWP.AREA.COND. RECPTM WORKMAN COMPENSATION DECLARATION SCHOOL TAX, YN
❑ Thereby uBoom that l have a ccni0cad ofconunu0 self-imam.or a cenificam of FIXTURES-PERTRAP RECEIPT#
Worker.'Compensation Increase ora candied copy thereof(Sce.3800.LabC.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'#
Pi BUILDING DIVISION FEES
Company d. GAS-EA.SYSTEM-OVER4 TEA) PLANCHECK FEE
❑ Cenilied copy is Filed
the city
tpG CenifeJ copy is filetl with thecityinspectian division. GRFASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
Y CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(9bissceion need not be completed ifrhe permit is horticultural dollars($100) SEWER-SANITARY-STORM EA.200IT. ENERGY FEE
Ics.)
I certify that in the performance of the work I which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Person in any manner so as to become subject to the WorkersPAID
Comprnsation Lawsof Califomia. Date WATER SYSTENBTREATING Dam Receipt#
Q Z Applicant
z NOTICI7 TO APPLICANT:If.after making this CeriEcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ep. A�E
OTAL:
become subject the Workers Compensation provisions of the Labor Cade,you most
a 7 forthwith comply with such previsions or pamsit shell be deemed mocked. E
P. CONSTRUCTION LENDING AGENCY z thereby affirm that then is a conswetion lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) OTA ELande/a NamepLanders Address QTY. MECHANICAL PERMIT FEE EEI certify that 1 have read this application and Stam thatre above informationcorrect.l agree m comply with all city sed county ordinaaccs and state laws relating to PERMIT ISSUANCE FEEbuilding construction.and hereby authorize repreecmmlvesof Nis city m enter upon the
z above-mentioned property fur inspection pugnses. ALTER OR ADD TO MECII. ON TAX
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
Iiabilities,judgments,cost;and ex n swhichmmyinany way ncerueageinst saiJCity AIR IIANOLING UNIT(TO IO,oW CPM)
in consequence of the graatin ism it. p
AIR HANDLING UNIT(OVER 10,000CPM)
Signamreo[ApplicanUCantmcmr Dr. EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I ILOV BTU) Done Receipt#
Will the applicant or future building occupant store or handle hazardous material
,is defrost by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,001)BTU) TOTAL:
Cade,Section 25532(.)'1
❑Yes 0N VENTILATION FAN(SINGLE RESID)
WIII the ecommntorfumre building bythenmu equip mem ualitceswhichemit
BOILER-COMP(3HP OR 100,000 BTI)) ISSUANCE DATE
hazardous sir ye,' nan1 as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU P p 0 D
• Uisuictl ) W
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have mad the hazardous materials fequircmems under Chapter 6.95 of the DEC 0 �g9
California I lealth&Safety Code,Sections 255(15,25533 and 25534. 1 undersand that
if the building doe. a
not currently have a anent,that it is my responsibility to notify the
occupant
pa ncof he requirements which must be met prior m issuance of a Certificate of •CII r Vr t sV
Owner or autbanzad agent Dam
TOTAL: ISSUED BY:
OFFICE