25262 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ B LLDING-KLLC'IECAL PERM]I'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C -C
BUILDING DIVISION BUILDING PROJECT IF'ICAT'108 J v
BUILDING ADDRESS: SANITARY NO. APPLICA'II[ON SSU�BM�I'ITAL DATE
��. UNO'k LOT#
OWN SNAME PHONE: C.pNQ'�AWR'S NA _ � LIC f —V
V H\\ N/C COM"ROLN
111'I'li f/F.NGINEER: LIC NO: DOKLSS: r El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEEL BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
I PERMIT ISSUANCE ❑ ❑
LICENSEDCONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL
°yz I herchydHummm lam l'¢enscdunder provisinnsofChap¢r 9(cnmmencingwith JOIf DESCRIPTION
WOO Second 7").f Division 3 of the Business and Professions Cade,and my license is in PANELS �f
SID{{'',� full forocand eft
FZW Licen.v�`.C,L"q—pe`�t�a•' Lick UP T02W AMPS
y
" 'wase
vii Dam 3Comrnclo .� 201-1000 AMPS SQ.FI'.FLOOR AREA S/SQ.FI'.
FyZ ARCHI IECTS DECLARATION OVER IM AMPS
'Om— I undcrstradrayplansehall be usednn Public actions.
.NFC SIGNS ELECTRICALI 4 L E � II �II
Licensed Profeaiorml - '1 II v
OWNER-RUILDER DECLARATION SPECIAL CIRCUIT/MISC. r�
•OiU I hacby affirm thin I am exempt from the Contractor's License Law for the LGL/
3 u,y following reason.(Section)031.5.Business and Professions Cade:Anyciy or c"umy TEMP.METI3R OR('OLE]NST. ))) G
which rc,aires a froadi to construct,a,tcr,improve,demolish,or repair any slmetor,
i� prior to its ismance,also requires the applicant for suchperanil to file a signed statement POWER DEVICES
!NM.
G O that he is licensed pursuant o the Provisions of the Contractor's License taw(Cluprtr
❑ SWIMMING POOL ELECTRIC
a VALUATION
•X., 9(cammcncingwith Soct an"lOgl)of Divisinn9of Ne Buaincaa and Pm[cae dna Codc)
W_, or that he is exempt lhemfrom and the basis forthe alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Z 4 Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
SO nrn more than fivchundred dollars($SW). NEW RESIDENT1ALF,LECTR _SQ.FT. S"IORIES TYPE CON S'HE UM]ON
W 1—� ❑ 1.asownernflheproMmy,ormyemployeeswithwagesmtheirsolecompcmmion,
y3_ will do the work,mndtbe swcmm is not intended oroffered forsale(Scc.]014.Business
and Possession,Code:The Conamcum's License Law does not apply to in owner of
Properywh"btildsorimpowestbctios.andsvhodoessuch work himselfonhrough his AGROUP UNITS
own employees,provided thatsuch improvememsumnotimendedoroffered forsals.IL
however,the building or improvemem is sold w,thin oneyear of completion,the owner. 'TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,us owner ofthe pmpeny,om cndusivclycnntraming wi@lianscd mmmemmo
construct the project(see.7014,Business and Prnfesciv is Code:)The Contractors
License Lawdoeanotapply Loan ownerofpropcny who builds or improvesthereod,and PERMIT ISSUANCE
vImenmmets for such projects with a eontraerods)licenmd Emission""he Coulmadrx
License law. AL'I'17R-DRAIN&VENT-WATER(FA) FEIi SUMMARY
❑ I am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE. UTSIDI:FEES
SANITARY Y N
Owner Date DRAINS-FLUOR.ROOF.AR LA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ IM1crchy alRrm lhatlhave ucerti0c:na of consenuo sdf-in sure,"racertiftvmnfFl%'IVRES-PER TRAP RECEIPT#
Workeri C"mpenmti"nlnsurm¢wracenifiedc"pY lhermf(Sec.JSW,Lab CJwhi<h PARK FEE YN
5 + RECEIPT N
rovers all Iq c R 1 GAS-EA.SYSTEM-1 INC.40UTLITS BUILDING ECEIPDIVISION#FEES
Policy# —
Compar, I M I i GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
CmifiW espy is filed wish the city imper ion Jivisiun. GRIASFflNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASETRAP SOILS TEE
COMPENSATION INSURANCE
(This section need not be,completed ifthe permit is for one hundred dollars(SIW) SEWER-SANITARY-STORM EA.2WFT. R- ERGY PER
or less.)
I cmily that in the perfnrmunirtartar wask for which thispermit is issued,(shall WAT12R HEATER W/VEN (E'LEC1'R
not employ any person in any manner s"as m become.subjeNt m the Workers PAID
Compensation Lawsnf Califomia. Date WATER SYSTEMITREATING Dam Receipt#
O
z A Iicam
z 0pp NOTICE TO APPLICAN :IL nhcrmaking his Ceni team of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rCn Income,subject o the Worker's Compensation provisions"(the Labor Code,you must BUILDING FEE
a forth.ills comply with such provisions.,,his permit shal l be deemed revoked.
W Q CONSTRUCTION LENDING AGENCY SEISMIC FLI:
z I hereby affnm thin there is a scm,ameti"n lending agency or'he perfomtance of
V O Nm w 9'/,e work far this permit is ironed(S..30Cis.C) TOTAL: ELLCI RIC FEE
lender's Name PLUMBING FEE
E.E. lender.Address QTY. MECIIANICAL PERMIT FEE
0 U 1 certify that I have read this application and state that the above information is
MF.CIIANICAL FEE
correct.Iagree et comply with all city E,and county ordinances and state laws relating to PERMIT ISSUANCE
�
sYll building construction,and hereby amhodae representatives ofthis city insider upon the CONSTRUCT ION TAX
U Z eWvcmammned property for inspection proposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify and keep harmless the City of Cu,armro against
(sties,judgments,costs and expenses which may in any way accrue against said City AIR I]ANGLING UNIT(10 10,000 CFM)
ceIs . "(the grand o t is pcmtit AIR HANDLING UNIT(OVER LR030 CFM)
S' roof Appli<anas"mmc'a Da¢ EXHAUST HC)DD(W/DUM)
PAID
ILAZARDOUS MAT 1 'DISCLOSUR' I II?AT'INC UNIT(TO 100.000 BTU) Date Receipt k
Will theapplicant or future building occupant atom or handle luoddows mabodsl 000 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the llealth and Safety HEATING UNIT(OVER 100. TOTAL:
Cate,Section L5532007.`,,,...///''' VENTILATION FAN(SINGLE RESID) �s
❑Yes ya No
/` BOILER-COMP(3111?OR 100.000 PTU) ISSUANCE DATE
wl1 the avvhemt air metre naodmg«moan nae egaivment ordevices which emit
hazardous it contaminants res defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) p D
District! Y1
❑Yes �QNo NEW RESIDENTIAL MLCII.—SQ.FT.
I have read 0¢hmardoss maerialn requirements under Chapter 6.95 of the SEP 1 7 1993
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand thin
if the building dros mat curently have a anted.Nm it is my responsibility to notify the s
In I'D'
'lie requirements which mu.% he met prior Ise issuan of a Certificate(if
CITY V Vr CI'(1 II
UCS
I o.amhorizcd agent TOTAL: ISSUED BY:
OF ?