25389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING
CHANT A. PERMIT NO. 25389
APPLICATION/PERMIT PLUMBING,-MECIfANICAI,
BUILDING DI VISION BUILDING PROJECT IDENT'IF'ICATION
BUILNOADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DKK:
UNIT# LOT# 1 1
D ERS NAME D PHONE: CONTRACTOR'S NAME: LIC N0:
NC CONTROL#
CIIII'ECT/ENGIN[ER: LIC NO: ADDRESS: - ❑
CONTACT: PHONE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pmzz Ihereby affirm that l em liceneedunderprovisions of Chapler9(commencing with JOB DESCRIPTION
F 00 Semi on%100)of Division 3 of rhe Business and Professions Code,and my license is in PANELS
auk ranfame /� /�
tier<a Date
CClus ,.� 6 Contocmr �J UP T0200AMPS K ' n 1 at—
1-yZ - • ARCHIIF.CTS DEC1.ARgT10N IDI IOOO AMPS !! LU 1/I/WH'
j0 z0� I understand my plans shall ed used as public records. OVER 100JAMPS
SQ.FT.FLOOR AREA S/SQ.FT.
F 1.2 SIGNS ELECTRICAL
Licensed Puireesinnnl
E:=W< OWNEUBUILDER DECLARATION SPECIAL CIRCUIT/MISC.
k0 U 1 hereby affirm chat I am exempt form the Contravenes License Law for the
F 5 tl-i following tea un.(Section J031.5,Business and Pmfessions Code:Any city or county TEMP.METER OR POLE INST.
y n which-quires u permit or construct,alter,improve,demolish,of repair any sm rmm
sp WDM prior-its issuance.also requires theapplicant for such permitmfileasigned samment POWER DEVICES
e,'<0 that he is licensee pursuant to the provisions of the Contractor's License Law(Chapter
oLL 9(commercing with Section 91100)of Division 3 of the Business aSWIMMING POOL ELECTRIC tied Professions Code) VALUATION
or that he is exempt therefrom and the baaisfor the alleged exemption.Any violation of
f.zQ Section J(131.5 by any applicant for a permit subjects the applicant u civil penalty of OUTLETS-SWITCHES.FIXTURES M<
'1-0_M< not mom than five hundred dollars($500). yf Cl
KI'-o ❑ Losownerofntepropcny,rrmy<mplryeeswintwag<s astheirsrlecompensedon, NEW RESIDENTIAL ELECIR SQ,FT. STORIES TYPECONSTRUCI'IOb
a 3°O will eothe Professions
and the he on tis tot's License
Law does of apply to an,Business
and proparty wh ons Cade:The Contractor's nd who Law uch not apply lf an owner of p
ownertywyers,pesorimpmveuchimprandwhnammot mi work himsdforthrougM1 his t I t
employees,providedthmsuch improvement venotimendedorofferedforxale lL '�r L C.G I RES.UNITS
however.the building or improvement is sold within one yew rfcompleime'Imowner- 1 I ter- g�
builder will have the burden of proving that he did not build or improve for purpose of O t !9I ,�.•(a
sale.).
❑ 1,asowner ofthe property,am exclusively contracting with licensed convectors to QTY. PLUMBING PERMIT FEE r ppN
construct the p-jeer,(Sea.7044,Business and Professions Coak.)The Contractors
License lawdocs not apply loan ownerofprmpcny whobuddsor improves thereof,and PERMIT ISSUANCE
whocontrvcts for such projects wentacarderw or(s)licensed pursuanuo the Convectors
License Law. ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis mason BACK FLOW PROTECT.DEVICE OUTSIDE PEES
Owner- SANITARY YN
Date DRAINS-FLOOR,ROOK AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm thmlhave acenifica-rf conunuoself-insure,cancerrifcam of FIXTURES-PER TRAP RECEIPTp
kers Compensation tourer-drncenified way themof(S«.JSW,LabCJwhich PARK FEE YN_
oaCovers Ile lay h e Nisperme GAS-EA.SYSTEM.I INC.4OUTLETS - RECEIPT#
Policy# n BUILDING DIVISION FEES
Conpa^Y GAS-BA.SYSTEM.OVER 4(EA) PLANCIIECK FEE
❑ CanrTicd copy nes ere y 1 crushed.
g`Creificd copy is filed with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR
( GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for on<hand-ddollare($Mfi SEWER-SANITARY-STORM EA.2WFT. ENERGY FBG
orless.)
I ccnify Nat in the performaderifthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
no employ any person in any manner so as to become subject to Ne WorkersPAID
z Cionamsmirnl.uwsof Califer is. Dare WATER SYSTEMITREATING Dae Receipt#
O t
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB.F SQ.FT. TOTAL:V1 become subject to the Wurkers Compensation provisions of Ne Labor Code.you must
foMproor perme a«mri revoked.
with comply with such visions this shall b
� 7 BUILDING FF;E
Ca. CONSTRUCTION LENDING AGENCY SEISMIC ME
=) z Ihereby affirm the there is a construction lending agency for the performance of
U O the work for which this permit is issued(S«.309],Civ.C.) TOTAL: , ELECTRIC FEE
Lenders Name
Q U Lenders Address QTY. MER
MIT FEE PLUMBING FEE q �
I certify that I have mad this application and stere that Ne above information is f
FW comm.l agree-comply with all city and county ordinances and sort laws relating to PERMIT ISSMECHANICAL FEE
_ ,A building construction.and hereby authodee representatives erfebis city-emerupon Ne
U Z olxwc-mcmirnee pm,.y for inspection purposes. ALTER OR CONSTRUCTION TAX(We)agree to save,indemnify and keep harmless the City of Cupertino againstIiabilities,judgmcareacoses andexpenses which may in any way accrue against said City AIR HANDLCFM)fthegon' goo1his pdomt.icarniAIR HANDLIOD CFM)
. gnawre roof ppbcaMCon.,or,,, Dao EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1 W,t100 BTU) Dom R«cipt#
Will the the Caant ti mth-building occupant erre 2,andhardlethe
hazardous material
usdefinedio the Cupertino Municipal Cade.Chapter 9.12,and the Heahh and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL: j.
Code.Section 25532(a)?
❑Ycs 0N VENTILATION FAN(SING LE RESID) _
Willthcapplicum nr Numbuildin mere BOILER-COMP(314P OR 10X1,000 BTU) ISSUANCE DATE
goccupnn yuipmem araevices which emit
haeaWnus air contaminants a9 Defined by the Bay Arca Air Quality Management BOILER
District? -COMP(OVER 100,000 BTU) NpV - 111193
-
4 ❑Yes El Na NEW RESIDENTIAL MECH. SQ.Fr.
I have mad the hu.,mras materials requirements under Chapter 6.95 of the Y Ot (;UYtH I IND
Califmmia Health&Safety Code,Sections 255QI I
05,25533 and 25534. I understand Nat rt INNU
ifthebuilding does notments currently hevcast be that itis my responsibility to notify the C/
cupvm of the requirements which must be met prior to issuance Of.Certificate of
Occupancy. '
Owner or immoecom agent DoteISSUEDBy�