25234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO25234
MALIi NO-IFf.M A. - PERM]PNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT BEEN I'IFICA'I']ON
BUILDING A^DDRESS: SANITARY NO. APPLICA'GON SUBMITTAL DATE
/� RW/V NITN LOT# 6—,
OWNERS NAME. PHONE: 'CONTRACTOR'S NAME: LICNO:
! / /�// NIC 7 CONT�ROL/N�
_Wy RC1 I:CTB:N NF k: n I.IC NO: ��(T ADDRESS. �� 6 �[�F# VQxI �G C c✓
CaNTACIlLf�I/�G,/�,//�•� Lyyy�/-�_// PHONE: L"ry>4I (F QTY. y ELECTRIC(PERMIT r E BUILDING PERMIT INFO
BLDG
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEM'(Al. JOB DI'SCRIPI'ION
Matz I hcrehyaffmUhat l nm liccnxcdundeo provision .02hapter9(ccmmencing with -
PQ00 Sectinn7000)of Division 3 mftheBaseness and Profclomns Code.andmy liocnse is in PANELS T $- 1'
tC�j full limaunA effect. l lr VI/ V1�
QZ I.ic Lic.p < UP TO 200 AMPS
vFi6 mel=s ennoac My.f/,) 201-IOBBAMPS
Z Oy a ARCHITECT'S DECLARATION OVER AMPS SQ.try.FLOOR AREA p�$/SQ.PI'.
CZ-0 I understand my plans shall be used ss public records. ,3S�7S 7µeJV
.N�d-I Licensed Professional L
E:=< OWNER-BUILDER DECLARATION PECI R /MISC J
KOR! I hereby affirm that 1 am exempt from Ne Convenors License law for theM. 1 -sJ L
W 3 a y following reason(Section 7031.5,Business end Professions Code:Any ,city doe utny, M BOB POI
which requires a permit to construct,elteq improve,demolish,or rtpeir any nr adome� 1
ftrts^��Y� prionoits issuws,,also mquires the applicant forsuch permiuo filensignWstmemem DEVICES l Q l
0Oq Inot he is licensed pursuant to the provisions of the Contractors License Law(Chapter kC
d eLL 9(emonencing with Section 7")ofDivision 3 ofthe Business and Professions Cale) SWIMMING POOL ELEGVALUATION
Mot or that he is exempt therefrom and the basis for the alleged exemption.Any violation of n( (p) 7 ) /+O
F Z Q Section 7031.5 by any applicant for a permOUTLETS-
it subjects the applicant to v civil Penalty of SWITCHES-FIRF.S •--S e I
K � not momth:mfivfthepmday,ors($5m). NEWREMEENTIALELECIR _SQ.FT. STO ES TYPECONSTRULTION
❑ ,he wrk,andepmpeny,ormyempended roffeegesustheide(Sce,compem mess
will dmhe work,and the he Condructum is not intended L.wrdowed net
apply 1.oil owner of O
and 1'rol'cesinnx Gale:The Connacror's License Law date urn apply In rot owner of
prnlxny who M1ullds nr Improves thueen,end whodooe each work ldmselfnr lhnmglWf, OCC.GROUP RES.UNITS
how a er,the
tbut such improv ld within
n e imm�ded mplelio ,Itico e.If,
howcer ,will have
the burdenovementisseldedidnet build
oimprove for purpose of
builJer will have the burden of proving that h,did not build or improve for purpose of
sale.).
❑ Las owncrofthepropcnm y,aexclusivelycontmcting mo
with licensed conum to QTY. PLUMBING PERMIT FEE FLOOD ZONE AIN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
I.icensel,owdoeanotapplytoe ownerofMr ory who buddsotimproves lhemon,and PERMIT ISSUANCE
wbocommns for such projects with a emaracom s)licensed pursuant m the Convectors
License law. ALTER-DRAW @VENT-WATER(EA) FEC SUMMARY
❑ 1 am exempt under Sa. .B @ P C for this¢awn BACK FLOW PRO PELT,DEVICE. OUTSIDEFIHIS
SANITARY Y N
Owner Data
- RECEIPI'N
DRAINS-FL R.ROOF.ARE A,COND.
WORKMAN COMPENSATION DECLARATION 100 A% YN
I❑ Ihercbyaflitm that i have a cenificate uftomentto self-inure,oracenificme of 1 'I RECEIPTp
Fl%TURPS-PBR - L.
Wrnkcrs'Compensation Insurance oracenifiedcopy Nertof(Sec.3800,Lab C.)which � PARK YN
coven all employee's und,nhis permit GAS-EA.SYSTE W :40UTLITS 1 1 RF.CCIITp
Pnlicyp 5 _ j� BUILDING DIVISION FEES
Cam ty GAS-EA.SYSTEM- VER4(F.A) P CIi'.CK FEE
Cm'tIOM copy is hereby(umishcd. ''g�ak�G'
Certified copy ix filed withthe city inspection division. GRRASIVIN STRLn�t WiF=p RADA FEE DO'^
CIiR9'IFICATE OF EXEMPTION FROM WORKERS' GRFASLTRA - - SOILS PF:F: 0 'QV
COMPENSATION INSURANCE
(This section need not b,completed iftbe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE U
orless.)
I cenifythm in the performanceuf the work for which this permit is issued,IshmI WATER HEATER W/VFNT/ELECI'R /
not employ any person in any manner so as to become subject to the Workers' PAID—
z
Compensation Low,Lows of California..Date WATER SYSTEM/TREATING Date Receipt#
Applicant
z 0 NOTICETO APPLICANT:If,after making this Cenificam of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: s
y become subject o the Workers Compensation Provisions of the labor Cnde,you must
� ; forthwith comply with such provisions or this permit shellMdameJ revoked. BUILDING FEE 7-M
0. [] CONSTRUCTION LENDING AGENCY SEISMIC FEE O.YQ
1 hereby affirm that them is a construction lending agency for the Performance of
UO the work for which thispermit is issued(Site3097.Civ.C.) O ELECTRIC FEE `
25
L<ndcrs Name
OF" Leader's Address _ QT'Y. MECHANICAL PERMIT FEE PLUMBING FEE `
V I certify that I have mad this application and state that the above infmm umn is
W torten. I agree m comply with all city and county ordinances and mate laws relining to PERMIT ISSUANCE MECIIANICALMP
�-' Cn building connmcfmm,and hereby authorize representatives ofthiscity to enter upon the CONSTRUCTIONTAX
U it v,nma6dnedpropm1y l'or inspection purposes. ALTER OR ADD TO NIECE I.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
I iahi It lles,juigntents,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
meiryenc,ofit m granting of thi permit.
�,- AIR HANDLING UNIT(OVER IQgXI CFM)
Signature of ApplicamlCnnvacmr Date ME MUST HOOD(WA)UCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN."BTU) Date Receipt#
Will the applicant or future building occupant store or handle hvnrdeus material IIEATWG UNIT(OVER 100,11(X1 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(v)?
❑Yes ❑No VENTILATION PAN(SINGLE RMID)
whichemit
BOILER-COMP DHP OR BlIg1B BTU) ISSUANCE DATE
Will the applicant urfmtuehuildingacvpant useequipmrnmrdevices
a nodous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,W)BTU) r pp
A I D
Stncl?
J ❑Yes ❑No NEW RESIDENq'IAL MFCII. SQ.FT. OQ
I have read the hazandous muicnals mcmiremema under Chapter 6.95 of the _ SEP as 9 1993
California llenith @ Salety Code,Sections 25505,25533 and 25534. 1 undervland that
iflhe building does not currently have a tenant,that it is my nespnnsibility In notify the a'
rccnpam of the mquiremerde which must he met pnoo to issuance of a CertifemCITY Ur 1XUrG
,of V
Occupm Ot.
Owner or uwhuriv.ed agent - Date O ISSUEDB