25122 APPLICANT TO FILL IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUIIAIINU-ELEC I RICAL PERM]FNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING:PROJECTIDENTIFICAT'111N 5 el n n
J 1 L L
BUILDING/`ADDRESS: /�� �' ,f 7� Ig/r�L�1/{,/� SANII'ARYNO. APPLICATION SUBMITTAL DATE DATE
L/ I GIV 1 W 1 I ter UNIT# LOT is
O ERS NAME: I /
1 /`HONE: M C 'I'RACIOR:S NAME: LIC NO
IWNIC LONG ROL#
•A CIII EC piNGINF.LR: LI NO: ADDR SS: I C ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEC
Bs ELECT PL MB MECH
r✓�1AM1\r PLRMIi'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RPSIDENITIAL , LOB C O
C=Z Ihereby offirm thin l am licensed under provisions of Chapter 9(commencingwith
tc100_ Section 9000)of Division 3 of the Business end Professions Code,and my license is in PANELS
Yt�{{'''' full force and effors. �y�
<Zµ Lice ss Lic.a UP TO DBD AMPS '
iv
y66 c Cantmc r - 201-third AMPS
Z OrNirN � ARCf "P ECLARATION OVER I(NIBAMPS SQ.FIUTAOR AREA $/SQ,11,
0Z JelbAun x d Iaspublillrewrds.
Piz, nn SIGNS HLHCTRICAL
Q veJ n c. nnnl
aa'' 0.' OWNER-BUILDER DECLARATION SPECIALCINCUIT/MISC.
KOW I hereby affirm that)am exempt from the Committees License law for the
Mon following rensom.(Section 7031.5.Business and Professions Code:Any city or county TI?MP.MHTE QR T
y� which requires u permit m construct,alter,improve,demolish,or repair any structure
fyr7 prion.its issuance,ulsomquimadeapplicarm(a,such perom to file.sil,edsutamce, POWER UCVI
y�ja DO that he is licensed punuanfto the Provisions of the Contrectaes License Law(Chapter SWIMMING E VALUATJ g
aao� 9(commencing with Section]000)ofDivision 3 of the Business end Professions Code)
W_, or that he is exempuherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWIT RES ��/1�
F Z Q Section 7031.5 by any applicant for a pemd,subjects the applicant to a civil penalty of
C
d more than five hundred dollar(55Wk o m❑ 1,a+ownenfNc progeny.ormyemploymwiNwagesuNeirsolecompensntion, NEWR LAI.ELECTR _SQ.FT. STORIES TYPECONSTRUCIION
a3Lo will do the work,and the structure is not intended or offered for We(Sac, Business
.it Profession,Code:The Contmaoes License Law does not apply to sm owner of
property who buildsor improves thereon,and who does such work IthaWforthrough his OCC, RIS.UNITS
ownemployecs,pruvidedthet such improvememsert notintcndcdoruffered 6r We.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the hordes of proving that he did not build or improve fm purpose of TOTAL:
sale),
❑ I,as owner ofte,property,am exclusivelycontmcting with licensedcontrectorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec,7044,Business and Professions Cade)The Contractor's
License Law does net apply mon(,wnerafpropenywh.b.ildsorimproves therean.und PERMI'TISSUANCE,
who contracts for such projects with a contmctogs)licensed purseCon
uano the tractees
License law. ACI'PR-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I um exempt under Sec. ,B&P C for this reason BACK FLOWPROTECT.DEVICEl TSID,FEES
SANITARY Y N
Owner Data - RECEIPT'#
DRAINS ROOR,RDOP,AREA,COND.
WORKMAN CDMPENSATIONDECLARATION SCHOOLTAX YN
❑ Iherehy affirm that lhave aaruficam of consent to self-insure.oracen certificate of RCCEIPI'#
•IXI UNIS-PEN TRAP
Workers P.Campensmiunlndthrocenifcd copy therrof(Sm.3g00,1,nM1CJ which PARK ITY N
rsall employee's underirthiss permit. GAS-G.SYSTEM-I INC.4 OUTLETS RD '#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifedcopyisherehyfumishad.
❑ Cenified copy is filed with the city inspection division. GREASPJINDUSTRL WASTE INTERCEPTOR GRADING FE-H
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASH TRAP SOILS IRE
COMPENSATION INSURANCE
(This sectinnnadrot be completed ifthe permit is foronehaidreddollars($IN) SHWHR-SANITARY-STORM EA.2001T. ENERGY FEE
or less.)
I certify that in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person in any meaner so u in become subject to the Workers' PAID
Compensmionlawsof Cnliferna Data WATER SYSTEMfTREATING Data Receipt#
0 z Applicant
z O_ NOTICE'I'O APPLICANT If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ,FT. TOTAL:
C01 heccmesubjecnodhe Worker's Compemmion provisions oftbe Labor Code,you must
C: > forthwith comply with such Provisions m this permit shall be deemed revoked. BUILDING ME
CONST RUCTION LENDING AGENCY SEISMIC FEE
"U z Ihershyuffirtn that tberc is a reml...Imn lendingagency for the perfarmanceof - ELECTRIC PCE
O the work for which this Permit is issued(Sea.3097,Civ.C.)
Lender's Name -
O U Lendar's Addicts - QTY. MECHANICAL PERMIT PRE PLUMBING FEE
1 certify that I have read this upleheaf on end scam fled the above information is
OW-t comae. Iugrecio amtply wllh ell city ural county uNinancee and stale laws relating to PERMI'I'ISSIIANCIi MECHANICALFEE
LI) hu' gs. atrudinn,mndherebyauthoriumpmsentadvesofthiscitytoenteruponilie CONS'I'RUCI'IONTAX
U z demi reed prn;,n for inspersion purposes. ALTERORADDTOMECIL
ave(n e)hree to save,indemnify and keep homeless the City of Cupertino against
limbi', inerts,cost fidespemes which may in say way accrueagainatsaid City AIR I IANDLTNG UNIT(TO 10,000 CFM)
nsc a fd ( ofthisparr id.
AIR HANDLING UNIT(OVER 10,000 CFh3)
Si pp icon te MHAU.ST HOOD(W/DUC1')
PAID
HAZARDOUS MATRRIALS DISCLOSURE I[RATING UNIT(TO IN,"BTU) Data Receipt#
Will the applicant or future building occupant store or handle hactrdous material BEATING UNIT(OVER 100,(80 BTU)
defined by the Cupertino Municipal Cade,Chapter 9.12,a�the Health and Safety
Cade,Section 25532(a)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
Will the applicuntorfutumhuddingacupant macquipmenmrdevices vehichemit
BOILER-COMP(311P OR 100,(1(10 RTU) ISSUANCh DATE
haurdoma air coam
mtimo rs as defined by the Bay Area Air Quality Management - BOILER;-COMP(OVER 100,000 BTU)
UlStrlC!? pp
1p ❑Yes ❑No NEW BESIDENfIAL MECH. SQ.FT, PAI
p I 0
I hove read the Lamnlous mmeriuls raryirements under Chaprer 6,95.1 the
Culiromin I Ivalth&Safety Cude,Soations 255115,25533 and 25534. 1 ood...tend that MAY
if the building docs not currently have u tenant,that it is my respamsibilidy to notify tYilglA
he II 51993 rsana
ccupant of the requircrdcros which must M1e met pnor to issuance of a Certificate of _
Oceipancy. 1 I ,
Owner nr umkmud agent DateCfI Y urq7
< � TOTAL; ISSUED BY: