25608 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BI LVN -MLIAAHICA. PERMITNO.
APPLICATION/PERMIT PLUMING-MECHANICAI. 25608
BUILDING DIVISION BUILDING PROJEC7IDENTIFICATION
B UILDING ADDRESS: SANITARY NO, APPPLICATIONNSUBMIMITTTALDATE
I'N ( UNIT# LOT#
OWNERS NAME:: PHONE: CONTRACTOR'S NAME: I � LICNO: eta ���_ �•••////
ArNIU0,T- 2 3- D My ro vcTp a N/C CONROL#
,RCI 111'HCT/ENGINEER: - t LIC NO: ADDRESS: ❑
LA✓a,a
aNTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PF.RMITISSUANCE BLOC' :LF.CT PLUMB MECII
fNJt` ❑ ❑
LICENSED CONTRACTORS APPLIANCES-RFSIDENI'IAL
y.L lhereby 7")oafford Diviathat l3 and arms,sed Busins�rprn Prolloders,ns Castle,
9nd mmecense with OB DFSCR�O
500❑ Scnion]OW)of Division3 arms,puniness and Professions Code,and my license is in PANELS
P�W fall'i"amceand effum. � UPT02WAMPS 4
at,
License Classy Liap .lJ
mdy Dain Cumulate, (y) mea<�"' 201-I Has)AMPS
Z FO y'r. , ARCHI'TECTSDI!CLARATION OVER 1000 AMPS x tSfj El'.FLOfO�kR AREAa S/SQ.ITI'.
Z Q I understand my plana shall he used as public records. III 11\0
F^k4J1 SIGNS ELECTRICAL 7I�VV
aa Licensed Rofnsionul
ay�V OWNER-BUILDER DCCIARATTON SPECIAL CIRCUIT/h11SC. ' ) \ t �" '( I
XOyF I hereby affirm that I am exempt it=the Contactors License law for the — q ij
WD: to fallowing oucon.(Section 7031.5,Business and Professions Coda Any city crcoumy TEMP.MITER OR POLE(NST. DA rE
Y.O¢ which rani.Or pcnnic to construct,ol¢q improve,demolish,or raped,any stmeturt
yu{5+� prior to its ismanm,also oximms he applicantfor such petimto file a signed swtement POWER DEVICES
TOt�D,✓_s¢OC he,he is licensed pursunnn the provided of he Contractors License Law(Chapmr
low 9(commncing with Section 7000)of Division 3 ofthe Business and professions Code) SWIMMING POOL ELECTRIC .VALUATION
_,n or iliac he is exempt therefrom and the basis for the alleged exemption.Any viohtionof OUTLETS.SWITCHES FIXTURES' 6�J
F Y Sndon?031.56yarsyzipplicam for aciam,subjects he appllcaot toe clvlllwnulty of
O
it,)[more hon Eve hundred dnllas(S500). NEW RESIUIiNT1Al.GLECTR _SQ,FT.
❑ I,mownerofthepro cny,ormyemployeeswihwagcsmtheiraolecompensution, STORIES TYPE CONSTRUCTION
a will do he work.and the structure is not intended conflicted forsale(Sec.709q Business
and Professions Cade:The Cmnracbrs License Low,does not apply to an owner of
pmpcny whabuildtimimpsom,x thereun.and whodessuch work himxlfortlexi his OCC.GROUP
HIS.UNITS
ownemployees,provided hm
m suchimprovee tame not iatendeduroffered foreale.If,
however,the buildingor improvement ssold within one yearofcompletion,theawnm-
builder will have he burden ofproving that he did not build or improve for purpose of
cale.).
❑ 1,asownerofhepmpcny,amexclusivelyconuactingwithlicnuda,mmaorsla QTY. PLUMBING PERMIT FEE FLOOD ZONE AI'N
construct the project(Sex.7094,Business and Professions Codc:)Toe Contractor's -
LicenseLowdoesnotapplytoannwnerolproperty whobailds orimpraves themon,tld PERMITISSUANCE t
whocconalls frruchpmjeets with acmnroadr(s)licereadpurs....wihe Comractm's DRAIN �
License Law. p !WATER EIA) FEESUMMARY
❑ 1 am exempt under Sec. ,B&P C for his reason OTGCfOUTSIDE FEES
BACK FLOW PR :DEVICE SANITARY YN
Owner Dae RCCEIPPp
DRAINS-FI.OGR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have s cenificateofmccamt mselGiresrna.m.cenificatn of FIXTURES-PERTRAP RECEIPTp
Wmkcr%Compcnsation lnsurdnceoracrnifcd copy thereof(Sec.3g00,lab C.)which PARK FIDE Y— _N_
covere all employee's under his permit - REC p
GAS-E.A.SYS'T'EM-I INCA OUTLETS
Policyp BUILDING OI SIGN FF.F.900
Co++pany GAS-FA.SYSTEM-OVER 4(CA) PLANCHECK FIRE
❑ Ceoilicd copy is hereby furnished. V
❑ Certified copy is fded with the city inspection division. GREASEANDUST'RL WASTE INTERCEPTOR GRADING IPA!
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SAILS FEE
COMPENSATION INSURANCE
(This section need not be camplendifche permie is(oronehundred dollen(5100) SEWER-SANITARY-STORM EA,200FT. ENERGY Fy%
m less.)
I certify her in he performarrecof the work For which this Permit is issued,l shall WATER HMTP.R W/VENT/ELECTR
not employ any person in any manner so as to beccane subject to he Workers' PAID
Compcnswian Lnwsof California. Dale WATER SYSTH1drrREATING )ace Receipt is
Q z Applicum
0 NOFFCF TO APPLICANT:If,after making this Cnificwe of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
Tex become subject to the Worker's Compensation providons of the Labor Cade,you must
mrffw4 ccn+ply withwela prusamreerr this parmithnll be deemedoevnked. BUILD( GREE
ING AGENCY
sz Ihereby afford that them is o mmvuln��ending agency for the performance of EI CPRE
U O the weaker which this pc.i,is issued(See300],Civ.C.) 'TOTAL: L L ICP:E .�
lend?.,No.
LL F lenders Address QTY. MECIdANICAL PERMIT FEE PLOMBINJ PEC
V 1 oenify that 1 have read his application and ..,bar he above information is
>' W comes. I agree to comply with all city and county ordinances and amts laws relating to PERMIT ISSUANCEMECHAN LW?C
00 building construction,and hereby auhonzerepresentaives ofibiscity tonmrupnoThe CONSTRICTION' %
T,J 'Z above-mentioned property for inspection purposes. ALTER OR ADD'TG MUCH.
(We)ii,mc to save,indemnify and keep ham!eas he City of Cupertino agtinat \.
Iinhili0cs,judgments,costs and expenses which may in any way accrue agaimc said City AIR I ANDLING UNIT(TO 10,006,CFM)
in cnnseyuence 'chc ranting of his pemtit / .
E /(/iJgay—/Yp`a—/—(�-- AIR HANDLING UNIT(OVER IO,WOCFM)
Signaure n! pplicanUComrvetor ate EXHAUST 11001)(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HFATING UNIT(TO 100.000 BTU) Receipt#
W ill the applicant or future building oecupa d share or haddle hazardous matelot
as defined by the Cupertino Municipal Cole.Chapter 9.12.and the Ilexlth and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)
0Yes No l VENTILATION PAN(SINGLE RESID)
' Will he npplicnm orfumre building tucupwn useegoipmem nrdeviccs whichcmit
BOILER-COMP(3HP OR 100,000 BTT ISSUANCE-DATE
hazardous air conmminants as delined by the Boy Area Air Quality Management BOILER-COM('(OVER❑ 100,000 BTU) pp
Unid'e<! �� D
Yes �'o NEW RESIDENTIAL.MF.CH. SQFTA
P.
eliI have read the hazardous materials requircmno under Chapter 6.95 of the OCT
Cf+mia Health&Safety Cade,Sections 25505.25533 and 25534. I unaerated that V V
tithe building does not currently have a tensor,that in is my mspomibility,to nmify the
rampant of he requimmems which must be met prim to issutum of a GutiGeae
Occupancy.
Ownenn aahnriced agent Dam TOTAL: ISSUED BY:
OFFICE