25235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO G11. "' PERMU NO
APPLICATION/PERMIT PLUMBINI:-MECIIANICAL 25235
BUILDING DIVISION BUILDING PROJECT,IDENrIFICA11ON
BUILDING ADDRESS: 9 t SANITARY NO. APPLICMIONSUBBMMITTALDAIE
10 /RE ? �r UNIT# LOT)
OWAMPHONE C NAP
cc� N/C CONTROL If
McAlA�/ Q
ARCHITF.0(ENGINEER: LIC NO: ADDRESS: �'j(7 XVE U ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ppZ Ihereby effininthat tun licensed underprovisionsof Chapter9(commenting with
00 Section 7001 of Division 3 of the Business and Professions Cade,end my license is in PANELS n
aV U fon r'me ane crr$,!2e2 1 x�l D / _ ��/
Z V UP TO 200 AMPS
y Date Contractor 201-1000 AMPS
ZQNz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.F1'.FLOOR AREA FT.
OZ�W n j�a-M_l sed "blic.cords. SIGNg ELECfA1CAl
<yield/Pmfes-u(onal''I '
=ty.6 / OWNER-BUILDER DECLARATION SPECW.CIRCUR/MI
KOaU 1 hereby affirm that I am exempt tram the Contractors License law for the 7
W 3 a ti following reason.(Section 7031.5,Business end Professions Code:Any city or county TEMP.METER OR Po (NST. I I,1
°•0 Q which requires a permit to conatmeL el¢q impnve,demolish,or repair any swewm -
�"Y� prion.its issust ce.rdso requires theapplicanr for such permiuo Mean....treatment POWER DEVICES
vLeti Q'0 that he is licensed pursuant to he Provisions of the Contmetor's License Law(Chapter
a p'po 9 with Section 7(Hgl of Division 3 of the Business and Professions Code) SWIMMING LELE VALUAg10N
(commencing ani )
UL_,, or that he is exempt therefrom and the basis for the alleged exemption.Anyviolationof
FZ¢ Section 7031.5 by any applicant for a pernot subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars(5510).
5,rap NEW RESIDENTIALELECfR _SQ.II'. S'1'ORI[S TYPE CONSTRUCTION
Lee: E] Las owncroftheproWrty.ormyemployccxwith wages nstheirsolecompensation,
6322 will do the work,and tM1eslrucme,i soon inleadedoroffcand farsalc(Set.]1N4,Business
and Professions Cede:The Cont.casr's License Law does not apply to an owner of
prnpeny who huilds nr improves theraoll,and whodncasueh work himself.,throughhiS
on employee,provided that such impreverse.samnot inlendcm
daff .ered Rated If, OCC.GROUP RES.UNIT'S
however,the buildingor improvement is add within one you m completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for puryose of
sale.).
❑ Las owner ofthe propm
property,aeaclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE F1 LONE AYN
anatmer the Inject(See.7044,Business and Professions Crde:)The Contractors
License Law docanot apply loan ownerofpropeny who builds or improvesthereon,and PERMIT ISSUANCE
w cerem mets fortieth projects with a mountains)licensed pursunm m the Contractors
License law. ALTER-DRAIN an VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE U'I'SIDE FEES
SANITARY Y N
Owner Date• DRAINS-FLOOR.ROOF.AREACOND. RECEIPT,WORKMAN COMPENSATION DECLARATION . . SCHOOLTAX Y N
❑ Ihacby affirm shell have acenifimat of coram 1.self-insurt,mnccrtificam of FIXTURES-PER TRAP RECEIPrp
Workers'Compensaion Insurance ora certifiedcopy themof(Sm.3l Lab C.)which PARK FEE Y N
covers ell la'm's Bdc t ' GAS-EA.SYSTEM-I INC.4 OUTLETS RECENT p
coDI
lic BUILDING DIVISION FEES
1 r P-Lf—s P GAS-EA.SYSTEM-OVER4 TAI PIANCHECK FEE
C,nified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION IROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Oris aceionnmd and be completed ifthe permit is faros,hundred dollars(S10(1) SEWER-SANITARY-STORM EA.20017. ENERGY ITE
or leu.)
I certify mat in the performanceof the work for which this .I,is issued,I shall WATER HE1VfTR W/VEN'DELECR
not employ any person in any rammer so u to become subject.the Worlmos PAD
Compensation Lawsof Califomia. Date WATER SYSTEM/TREATING Dae RmciPtx
Q Z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
bec.mesubject to the Workers Compensation provisionsofine labor Code,yoa must
� >
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC ITC
1 herebyaffirm that is a construction lending agency for the performance of
U 7. TOTAL: ELECTRIC FEE
O rM1c work for which this permit is issued(Sec.3097,Civ.C.)
Lendma Name PLUMBING FEE
Leaders Address QTY. MECHANICAL PERMIT FEE
U 1 eerily that I have mad this application and state that me above information is
correct l agora to comply with all city and county ordinances and stare laws relating. PERMIT ISSUANCEMECHANICAL FEE
F-' building construction,and hereby amhorim representatives of this city m enter upon the CONS'(Rl1C'1'ION TAX
U Z above-asonamed property In,inspection PUHxrncc ALTER OR ADDTO MECH.
(We)agree br save,indemnify and keep hamdas.s the City of Cupesina against
Iiabilitic,judgments,costvmdespenms which may In any way accrue against said City AIR HANDLING UNIT(TO 143,000 CFM)
in cnnsequerm althe granting of permit.
J � AIR HANDLING UND(OVER 10,"CFM)
Signa a of Appla,mc Contr to, Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,0430 BTU7 Date Receipts
Will the applicant or forum building ame,sam sore or handle husiumms material Of
sat defined by the Cupertino Municipal Cede,Chapter 9.12,and me Health and Safety HEATING UNIT(QUER tW,000 BTU7
Code.Section 255320)7 VENTILATION FAN(SINGLE RfSI D) ss,
❑Yes ❑No
ISSUANCE D TE
Will the applicant or futumbuildingoccupont toremmpment ordevic,s which emit I BOILER-COMP(3HPOR 100.0)0 BTU)
hazardous air com ardeaats u defined by the Bay Area Air Quality Management BOILER-COME(OVER 100.0110 BTU)
District] ❑ H. P A 1 p
Yes ❑No NEW RESIDENTIAL MECSQ.FT.
1 have rtad the M1aamdoms materials rcquimmcnts undo Chapter 6.95 of the �I I
California5
ia Health&Safety Coul Sections 25505, 533 and 25534rstamf.1 undemat u j
if the building docs not conically have o raaonL that it is my msponsibilay m notify the
occupant of the requirements which must be mer prior to issuance of a Certificate of /�
Occupancy. OIL,
1 L hlgry
Owner or arthoriud agent Date _ ISSUI_D BY: