25114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUI 1 GN I- `.ChLIRILAL ,PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IUEN'I'IFIC-A'IION 2511 4
BUILDING ADDRESS: ra SANITARY NO. APPLICNOONSUBMITTALDATE
oUCO I LOT# S
IOWNERS N - PHONE: CO RACTOR'S NAME: LIC NO:
r S• A 106 OA N
IC CON'ROLk
C 11 Ii I''/ENGINEER: LIC NO: A1>DRE S: K
CONT CI': PHONE: 1
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LDG ELECT PLUMB MUCH
PERMIT ISSUANCE 13 C1'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
Matz I hereby officiation L am licensed underprovisionsof Chaper9(commencing with LOB UESCRIPTLON
(+100 Section 7(100)of Division 3 ofthe Business add
rProfessions C e,and mylicense is in PANELS ;!�'��.lr��7�
F 'u`1afo eons off(t^ Lia.# r 1 coW 201TOI00DAMY5 �03
ZF- ARCHITECTS DECLARATION OVER I"AMPS SQ.F3'.FLOOR AREA S/SQ.FT.
O Z^@ I understand my plans shall be used as public reconfi,
uu11 SIGNS ELECTRICAL
Q sa,� hiansul Pmfcvsinnul
OWNER-BUILDER DECLARATION SI'RCIAI.CIRCUIT/MISC.
?JO U hereby x1Erm that tars exempt frmnat[,ahe Cnntrvctor'a license Law far 1M1a
tai Saya following mason.(Section]031.5,Busina.mid Professions Cade:Anycityorcoumy TEMP.METER OR POLE INST.
�c0t.3 which raluires a I'ennit to customer..]let,improve,demolish,or repair any ammune
prior to it issuance,also requires the applicant for such permit to Ne a signed statement POWER DEVICES
arjYpo that he is licensed pursuant to the provisions of the Contactor.License Law(Chander SWIMMING OLNIA aio� 9(commencing with Section 7")of Division 3 of the Business and Professions Cale) VAWA
Worn or he isexcmpt therefrom and the basis for the alleged exemption.Any violation of OVII GTS-S i I
�yQ Sodom7031.5 by anyapplicant for a pertrnincheauhe applicantma civil penahyof `
mom than fiv<hundrW dollars(SSW). NEWR&SIAL 'CI S .
W C31,asnwncndthepmperty,ormyemploycea with wegesasthei...lecompensmman. STORIES TYPE CONSTRUCHON
63� will clothe work,and the atrucatre isnot intended mothered!forsale(See.7w,Business DATE .�
and Professions Cam.
le:The Concmr's License Law does not apply td an owner of
properly who bu ilJs or improves shercon,and who Jaes such work himself or through his
UNITS
own employees,provided that such improvementaam not intended oroffered forsole.If. OCC GROUP RES.
however.the building orimprovemern is cold within one yearofcompletion,theowner- 'ITGAL:
builder will hove We hunlen of proving that he did not build or improve for purpose of
sale.).
ElI,ns.wncrnftheproperty.am exdmivelycnnuaming with licensed conunctoa to QfY. PLUMBING PERMIT FEE PLOOU ZONE A"
mmunict the project(Sec.7044,Business it Pnsfessinns Cale:)The Caucasians PERMIT ISSUANCE
License lawdoes not apply toanownerafproperty who buildinteracts sor impves thereon,and
w ho corn acts for such projects with a mmmu lar(s)licensed pursuantto the Contactors
Lies.Law. ALTER-GRAIN&VENT-WATER BIA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY �Y DF FEES N
Owner Data RECEIPT p
DRAINS-FLOOR,RUDE. GOND.
WORKMAN COMPENSATION DI3CLARATION SCHOOL TAX Y N
❑ Ihcmbyaffirm lionlnsuveecenifeniFieconxnnreof(Snsurgo,a bCftcma of RECLIPI'#
FUTURES-PER TRAP Workers Co,loye tinminsaanceoracenifieJ copy rM1ertof(Sec.3gW,LebCJwhicry PARK IIiE Y N
covers ell entployee'n under thio permit GAS-EA.SYSTEM-1 INC.4 OUTLLTfS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER4(EA) PLANCHECK FEE �e
❑ CmdHadcnpykicarebyfnt fished.
❑ Certified cagy is riled with that city inspection division. GRPASUNDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection random becampinedifthepcnnitic foronehundreddollaa(SIW) SEWER-SANITARY-STORM EA.MEET. ENERGY FEE
or less.)
I ceniFythm in the performance of the work for which this permit is issued,I.hall WATER HEATER W/VENTIELECIR
not employ any person in any m er eo as td become subject In the Workers PAID
Compcnsatimu Lawsof Califomin. Date WATER SYSTEM/TREATING Date Receipt#
Q Z Applicant
�zz-1 C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Fy M become subject to the Workers Compensation provisions ofthe labor Code,you must
[moi forthwith comply with such provisions or permit shall M1e deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm That there is a construction lending agency for the pen'ormanee of
'TOTAL: ELECTRIC FF.E
O lige work far which this permit is issued(See3097,Civ.C.)
lender's Name
V.
U Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING ala
U 1 rectify that I have read this application and elate that the above information is MECHANICAL LLE
0. corwr l agree tocomply wit all city and county ordinances ental sate laws relating to PERMff ISSUANCE
uj b!Jdingcntuwction,and hereby malso ismproxntatives ofthiscity mentor upon But, CONSIRUCfION TA%
V Z above-mcmioned property for inspection purposes. ALTER OR ADD TO MECH.
(We).,me 10 save,indemnify and keep harmless the City of Cape tino.,.just
I"-b Iiti s,I gments,costs de"Famas which may in anyway acmoeagalrut said City AIR HANDLING UNIT(f010,000CFM)
cc nfthe gran hM1'ep mtin •
/I ALR HANDLING UNIT(OVER IO.OW CFM)
am re of Appoem/Ccurnacim Date EXHAUST GOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
[MATING UNIT(TO IW,WO BTU) Data Receipt#
Will the applicant r future building occupant store or handle hazardous mmerial HEATING UNIT(OVER I W."BTU) L.
as defined by the Cupertino Municipal Code,Chapter 9.17.and the Health and Safety
Code,Section 25532(x)9 VENTILATION FAN(SINGLE RF ID)
❑Yes ❑No
OOILER-COMP(3HPOR 100,03011111) ISSUANCEATE
Will theapplicant orf��umbuildingocapem useequipmem mdevices which emit �/rg p
.:ill
air comuminen¢az defined by Nc Bay Arw Air Qualify Management BOILER (OVER IW,(NIO BTU) P �A � �,
Dimnc
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
hza
have read The . rdous mmedals requiremu enunder Chapter 6.95 of the MA2 41993
Culifoon.I Icnith&Safety Co ic,Sections 25505,25533.ad 25534. I understand that
if ilm banding dues not currently,have.tenant.that it is my oxionsibility,to notify the
acupum of the requirements which most be mat pnor to issuance of a Ceniflcate of
Occupancy. ;f 1 1 y
Ur-
Owner
rOwner or uuthativcd agent Dam TOTAL.: ISSUED BY: /'