25439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - I� -RLeGTRi - PERM°"NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL LI
BUILDING DIVISION BUILDING PROJECT IDEN'I'IF'ICM'I(1N 5 /I J f� J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBaHFIAL DMT
L ►.nd— 3
UNIT# LO"1'p I.
OWN ERSN E: PH NE: CO TRACTOR'S NAME: LIC NO: NIC CONTROL#
N W C. L4
ARCHITECT'/IiNGINEER: LIC NO: AD KESS:
FiFZ tJ*D e SASE m.957Eo
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
uQ=z I hcrebyaffirrn that l um licensed under provisions ofaupter9(commencing with
JOB DCSCRLPTION
FO1O. fallComeOfattvismn3nf the Bminwsnn1d PPrroaf-eassion�sTCade,and my license is in PANELS \�,(
rZud License Clas � Lica LAri Tiot UPT0200AMPS
1�==y Datc Combustor •SnsaJl�Ar1DiK-/C 201-1000 AMPS SQ,IT.FLUOR AREA USQ,IT.
G FO NZ ARCHITECTS DECLARATION OVER 1000 AMPS
CZ-0 I understand my plans shall be used as public records. , t I� I w'
FrnFtu SIGNS ELECTRICAL 'i,�iT 1V
Licensed Professional
' CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ) ;j R
565��0�U I hereby affirm that 1 um exemm from me Cmmw,mr'a License Law for the ,il 0
u13 a Ef
v following reamn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. a�
F�-0 Q which requires a permit to construct,alter,improve.demolish,or repair any structure 34 /3
_J prionoits issuance,also requires the applicant(orsuchpenniuo fileesigned statement POWER DEVICES AIL'
SN that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
SWIMMING POOL ELECTRIC VALUATION
m.yxo 9(roirvnenemgwim5eefternandme Division Sof theBusinesscxcssand Professions Code)
W_w
or that he isexempt mmfromnt for
u Pens(subjeelkgeaenempti to Myviolationof OUTLETS-SWITCHES-FIXTURES
2E4 Section7031.5than
iv any applicant forapermit subjects the applicant ma civil pevhy of
not more own rofhundred dollars($500).yemp
�rS❑ NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONS'BUCIION
CUF� ❑ 1,esowncrnftheproperty,ormy employeeswitM1 wagesmtheirsole comperrsenon,
a3- willdathework,undthestr iumisnminwndMorofferedfors e(Sm.70M.Busimss
and Professions Code:The Contractors License Law does not apply to an owner Of
prnpeny who builds or improves thereon,and who Jaen such work himself or through his
OCC.GROUP RES.UNITS
employees,provided that such impmvemenmre
anm intendedoro(fend foraale.If,
however,the building or improvement is sold within One yew of completion,theowmc, TOTAL:
builder will have the burden of proving that he did Out build Or improve for purpose of
sale')' LO
QTY. PLUMBING PERMIT FEE FODZONE APN
C] I,vowncroftheprnimny,amexclusivelyconiractingwithlicensedcontmcrorsto
conswn the projeet(Sm.7144.Business and PmPossinds Code:)The Contractor's
I,icenselawdoeanotapplytounownerofprop whobuildsmimpmvest ce .and PERMIT ISSUANCE
who contracts forsuch projects with mearmactons)licensed pursuant to the Conrecmrs ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Linensu Law.
❑ 1 am exempt under Sec. .B&P C for this reason F I SIDE FEES
BACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF.AREA,COND. RF,CFIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm mut l have a certificate ofemswn to self-insure.or a cenilicate of FIXTURES-PER TRAP RECEIPTp
Wmkars Corniamantion lmcommir a cenified copy mereadgm.380o,Lab CJ which PARK FEE Y N
oRECEIPT
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS DIVISION a
BUILDING ON FEES
Policy a
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Carifiedcopynherebyfumished.
❑ CertifiedeWy is filed with the city inspection division. GREASEI[NDUSTTU.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not bscomplaed ifthe permit is fimone hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certifythat in me performance fthe work for which this period is issued,I shall WATER HEATER W/VENT/ELECfR
nm employ any person in any mannerso as
�I become s 6 t the Workers' PAID
Compensation (Calif Dee T` f0- N ) m WATER SYSTEM/fRGTING Dom Receipt#
Z Applicant s 1 C_Ci2nd) c;17 0HG i—S rc^=nf
0 NOTICE T'O APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. T'OT'AL:
yhecnme subject to the Workers Cma,mbion provisions of the Labor Cod,you must
forthwith comply with such provisions or this permit shall odem
deed revoked. BUILDING I9'E
WQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that mere is a construction lending agency for me p mrom ecce of
U O the work for which this permit is issued(Sm.3097,Co.C.) TOTAL: ELECTRIC FEE
Lenders Name PLUMBING ME
D" F Lenders Address QTY. MECHANICAL PERMIT FEE
1 cenily that 1 have read this application and mute that rhe above information is MECHANICAL.EEE
cost.l agree to comply with all city and county ordinances and sum laws relating to PERMIT ISSUANCE •V
E-' building construction,and hereby mithomn mpresentatives of this city to enter upon me CONSTRUCTION TAX
V mhave-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify send keep M1armless the City Of Cupertino against
Iiabilitim,tal ents,com'nndexpemes which may in any waymenre.,wristmaid City AIR HANDLING UNI'I'('1'O IO,OIXI CFM)
consequcn of c tin8 (this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signal r of Applican rector Date EXHAUST HOOD(WMUCID PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTI) Date Rcaipt#
Will the applicant or future halm,Occupant store or handle hazardous damenal BEATING UNIT(OVER 100,000 BTU) TOIAL_0,q, U
as defined by the Cu,,ioo Municipal Code,Chapter 9.12,writ the Health and Safety
Cod,Section 25532(a)T VE- LATION FAN(SINGLE RESTD)
❑Yes' ❑No
BOILER-COMP(3HP OR 100.000 BTU) 0 ISSUANCE DATE
Will air contaminants
as building by thentay equipment ordevlc Management P A
hazardous air comamiwnts us defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.IXq BTU)
•i
District?
El Yes ID No NEW RESIDENTIAL MECH. SQ.IT. rxnpap � O
1 time read the hazurdaus materials retmmotemm under Chapter 6.95 of the lW1Y�i�G•
California lieWlh&Safety Code,Sections 25505,25533 and 25534. I understand mer
iftbc building does not currently haver,amain,that it ism,rsponsibiliry to notify the filly Ur LUr r ri+lIVU
Occupant of the requirements which must be met prior to issuance of a Certificate of s
Occupancy. 1-^gip J� e
Owneror wnM1orizcd agent Dam TOTAL: \AQ
00 ISSUED BY:�'s�5f� �
OFFIC