25765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEBU
PERMIT No.
BUILDING UIVISION APPLICATION/PERMIT PLUM11MECHANICAL
ILDINfPROJECT IOFN'1IFICA310N 25765
BUILDING ADDRESS: SANITARY NO. APPLICA'170NSUBMMALDA'Iii
0 N R 'I". C(J NO/ � gawlf.
owl ME: PHONE: CONTRACTOR'S NAME: LIC NO:
m6kS N/C CONTROL
ARCHI JUC'I/HNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INPO
QTY. ELECTRIC PERMIT FEE
BLLO ELECT PLUMB MECH
PERMIT ISSUANCE tMV ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPf10N
qmz I hachyaffirm that l am licensed under provisionsofChaptee9(commenciagwinh
Poo Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
�yyU hall force License
Cladeffort UP TO 200 AMPS r^
GW License Class LIC.# '�JIY
rnQy Dau Comecon 201-I"AMpS
Z FO y ARCHITECTS DECLARATION OVER HIM AMPS ,A RS �ISQ'FT'
oz-WWWc
I understand my plans shell be used as public records. r-•`
Licensed Professional SIGNS ELECTRICAL I r`/�
L OWNER-BUILDER DECLARATION SPECIALCIRCUR/MISC.
xOiF- I hereby nmmr Nat 1 m exempt from the Conions Co License Law,for the
wa fallowing hereby
a (ration](1surn a emptBusinessfr and flue
Contras Code:Any city or county TEMP.METER OR POLE INST.
ON J which inquires a pemN to conswn,alter,improve,demolish,or repair any structure,
`�T� prions its issuares noc,alsonauishe applicam forsuch penNuo file asigred summoner POWER DEVICES
��YY Q p Nm he is licensed pursuant w Ne Provisions of she Contractor's License Law(Chapter
6 e� 9(commencing with Section 70nnof Division 3 ofshe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
W Asn or he is exempt Nerefrcm and the basis forte alleged exemption.Any violation of OUTLETS-SWRCHES-FlXTURES
[—. ¢ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
^M re Non five hundred dollars(ES(q). NEW RFSIDENTNL ELECIR 5 .FT.
K .asownerofNepropcny,ormyemployaswiN waguas Neirsolecompensation. Q STORIES TYPECONSTRUCTION
H9
illdoN-11 and Nestruaure is notinwn.
edoroffercd"am"(SecA044,Business
d Professions Code:qTa Contractors License Lew does am apply to en owner of
property who buildsmimpowes thereon,and whodmauch workhimeaforNmugh his OCC.GROUP RES.UNI IS
own employces,provided that such impravements mmotintended reoffered forsale.If.
however,the building or impmvcmem is sold within oneywofeampinion,Neowner- TOTAL:
builder will have the burden of proving that he did nm build or improve for purpose of
sale.).
❑ I,uawmrofshe Property,meadusivelyconteaing wiNliccnsedcontracnmso QTY' PLUMBING PERMIT ME ROOD ZONE APN
construct the project(Sec.7044,Business and Professions Cade:)The Connector's
License Law doesnm apply manowarmodpro,my whobuildsorimproventhemostand PERMIT ISSUANCE
who contracts forsuch projects with aconuach r(sHicensed pursuant to Ne Cartracmr's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em exempt under Sec. ,B&PC for this reason BACK OW PROTECT.DEVICE SANITARY 3
RY N
Owner Dau DRAINS-ROORNODFAREA.COND. RECEIPTp
M , ,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX YN
❑ Ihmby affirm that l have a certificate outimant to self-insure,or a mnificane of FIXTURESPERTRAP RECEIPT
Workers'Compensation Insurance or a cenifod copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
Cos.all employee's undo this permit GAS-M.SYSTEMA INC.4 OWL BS RECEIPT 0
Policy X BUILDING DIVISION FEES
Company
❑ CCertee ified copy is hereby famished. GAS-M.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed wids the city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEC
COMPENSATION INSURANCE
(This section need eat be completed if Ne permit is frronehundedi dollars Stan) SEWER-SANITARY-STORM M.200P1'_ ENERGY FEE
m lay.)
I certify than in the pafernanceaf Ne work for which this pertain is issued,l shall WATER HEATER WNENVELECTR
not employ any person in any member so ax to become subject to she Workers' PAID
CompenrationlAwsof Califomis. Dew WATER SYSTEMIMEATING Dom Receipt Is
,2 Applicant
NOTICETO APPLICANT:If,efwr makingthis Cenifieau of Exemption, TO
114,66
rCode.you should NEW RESIDENTIAL PLMB. SQ.FT.
LZ—� V: bechwitheome jccty it suchWorirs Compensation permit shall be
Labor aked. man
�i ; forthwith comply with such provisions or thin permit shell ba domed revoked. BUILDING FEE
per, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the perfmarohnce of
U O the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
Ixrder'a Nome
C U Lender's Address QTY. MECHANICAL.PERMIT FEE
PLUMBING FEE
U I certify than 1 have rend Nis application and sac a that Ne above information is
W cartons.l agree mcomply with all city and county oNinencn end nine levee mlasingm PERMIT ISSUANCE MECHANICAL FEE
building construction,and hemby auNmiu represenenvea of Nis city to anter upon Ne CONSTRUCTION TAX
U above-mealmost property for pancreases. ALTERORADDTOMECH.
(We)agree to save,indemnify ere keep harmless she City of Cupertino against
W�.nuc
cosuandexpe s whichmey ounryamyaccme.gainst said City AIR HANDLING UNIT(TO 10,000 CFM)
oft nn
AIR HANDLING UNIT(OVER UX000 CFM)
nUCa csar f CCau EXHAUST HOOD(W/DUCD f PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dow Receipt#
Will the applicant or home building occupant attire or handle harsrdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532p)? VENTILATION FAN(SINGLE RESID)
Cl Yes ❑No
. ISSUANCE DATE
WiUtheapplic imfamrebuildingmcuWtuwcuipmeotordevimswhichmit BOILER-COMPORPOR I00,"BTU)
ha srdom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DisVict7 ❑Yea 0 N NEW RESIDENTIAL MEER. SQ.FT. P4'Y{{�J
Y ® ,
1 have read the hasardaus materials hax ra emean nada Chapter 6.95d the �IIO�
California Healt &h Safety Cade,Sections 23505,25533 and 25534. I anderswnd Nm Itl ��
if the building does not currently have a tenant,that it is my responsibility to notify the eat
occupant of the requirecrome which must he met prier to issuance of a Certificate of CII r k7J
Occupancy.
Owner m i nhodwil agent Dine 'TOTAL: ISSUED BY'
OFFICE