25365 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '°ING.tal,EGTRTCAI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25365
BUILDING DIVISION BUILDING PROJF,C'r IDENTIFICATION
BUILDING ADDRESS: SANT"1'ARYNO. APPLICATION
S�UBMI'TT•'AAL DATE
O UNIT LOTH
ZZ v l l
� OWNE �MF.: / � P • CONTRACT'OR'S NAME: LIC NO:
' � `� LI/ N/C CONTROL N
ARCHITECENGINEER: J /LIICC NO:� N ADDRESS: y El
PHONE: a V BUILDING PERMIT INFO
19 QTY. ELECTRIC PERMIT FEE
TAP-375-8 B> ELECT PLUMB ME❑l
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RBSID IA
O C 2 I hereby affirm that I am licensed under powisionsefChapter9(commencing with TOB DESCRIPTION
+100 Section 700TH of Division 3 of the Business and Professions Code,ward my Bcense,is in PANELS
CWSF(�. to l oreemd stood.
<ZW Liccnu Class Lic.M UPTO200AM FAV �V
m?y Dale Co..., MI-I MP S b/SQ.FT.
,,FON% ARCHITECTS DECLARATION OYER IAWS
OZ-0 I understand my plans shill be used as public records. is
rrfooFW S CMCAl
Llccn.wd Profnsianal
OWNER-BUILDER DECLARATION S IAL CIRCUIEMISC.
x4x040 1 hereby affirm shad I am exempt from the Compactors License law for the
W'3 w h following reason.(Section 7031.5,Business and Professions Cede:Any city or county MP.METER PO IN
1_-v-so g which mqulres a pem+it m consdrun,aper.improve,demolish.or repair any xwcm
SW>� poor m its issuance,also requires the applicant forsuch permit to file a signed stele POWER DE
W_a0s that he is license,pnuoustn the provisions of the Contractors License Law(Chepmr SWIMMIN L IC VAL• yqy
o'K9(crnnmencing with Section 7")of Division 3 ofdhe Businessaral Professions Code)
e4
oaM, or thin be is exempt therefrom and the basis for the alleged exemption.Any violation of
OUTLETS- 1 HES-FIX ES
1ZQSection 7031.5 by any applicant for a permit subjects theapplicantto a civil pcnJtyof
-- Q^�
not more than five hundred dollars P6500). NEW RESID AL ELE Q.FT. F. STORIES V TYPE CONSTRUCTION
K � ❑ Lasowacmfdhepropcny,ormyemployms with wagesastheirsolecompensedonI
will do the work.and the smrcmre is not incendedoreffcreA for sale(See.)044,Bu sinus
and Professions Curie:The Contmemr's License Law does nod apply do an owner of
properly who builds or lmprove.c there(n,and whodou.mch work himselfor through his OCC GROUP RES.UNITS
own ever,me
ecs,provided pr suchent is sold
within
it ore not intendedorofferc,for oleo IL
howeverth<bulldic banderol
ismldwithinone year ofromplision.for theownn- TOTAL:
builderwill have dhc M1uNen nl proving that he did not M1uiIJ or improve for purpose of
I.asowner-filter properly.omexclusively contracting with licensed comment to QTY. PLUMBING PERMIT FEE FLOOD"LONE MIN
construct the project(Sec.70,14,Business arta Professions Code:)The Contractor's
License laxed«snot apply to an owncrof progeny whobuildsorimprovu Hereon,end PERM)TISSUANCE
who enatmcts for such projects with a contructor(s)licensed pursuantmme Conwctnr's
License Law. gLTF.R-DRAIN&VPNT-WATIiR(EA) FEE SUMMARY
❑ I am exempt under S<. ,B&P C for this reason BACK FLOW PROTECT.DEVICE '_SIDE EFS
SANITARY Y N
Owns. 'Uatc DRAINS-FLOOR,ROOF AREA,COND. RECHIPTp
IIS • cove s OR( 1AN COMPENSORION UECLARATIO SCHOOL TAX Y N
in
❑Workers
Co pensation Insavcacoa gicemcat copennoar'Sesure,m acmifi which,if FI%TURES-PER TRAP RECI.IITp
Workers'Cmmpenption lnsursncenncenifiedcopy thermf(Sec.3800,1ab C.)which PARK Ffeti YN
rs ell employee x under this perrnil. ECEIPT N
Y GAS-EA.SYSTEM-1 INC.INCO OIfTLETS
Policy b EEBUILDING DIVISION FS
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK Fl3F:
❑ Ccrlifi<J copy is hereby fumishM.
❑ CcnitiN copy is fled with the city inspection division. GRfiASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissecli.nnW not becamplcted ifthc permit is formahundrddollan(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or Icsv.)
I certify that in the performance ofthe work for which this Permit is issued.I shall WA3'ER HEA TER W)VENT(ELEC'I'R
of employ any Parma in any roamer so as to become subject to the Workrn PAID
Compereninn Lawsof Californa. Dote WATERSYSTEM[MEATING Date ReccipNl
O z Applicant
z � NOTICE TO APPLICANT:If,after trading this Certificate of Exemption,you should NEW RESIDENT ALP MB. SQ.F . TOTAL:
r !n beromc.mbject m the Worker's Compensation provisions of the Lma Code,you must BUILDING FEE
FC ; foMwith comply with such provisions or this permit shall be restated revoked.
OW, Q CONSTRUCT ION LENDING AGENCY SEISMIC FEE
I hereby affirm Nauhem is a consaucti P lending ag for the performmme of
Z) z .v TOTAL: ELECTRIC FEE
U 0 the work for what!210i Na, J C fVV;
Lender's plume "�JJ PLUMBING FEE
kt. F LcnJers A,Jmss QTY. MECHANICAL PERMIT FEE
U I certify that 1 have mad +is app i main a stem than the breve infd+Amtion is
MECHANICAL PEE
Lf-) correct l agree to comply with all city and county ordinances and stem E'laws odmingt. PERMIT ISSUANCE
F-' building construction,and hereby authods repreeentuliveaofthis city or cnmrupon the CONSTRUCTION TAX
Uz above"memi.mal progeny for inspection pudposes. ALTER OR ADD TO MECII.
We)agree to save,indemnify read kap harmless the City of Cupertino against
Iiubilines,judgment.custs andexpenseswhich may in any wayacemeagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
i. «uf dl+e gr m• lhisp
AIR HANDLING UNIT(OVER 10,000 CFM)
L
Slgnumre.f ApplicunVC.mrucu+r Date EXIIAUST 11130D(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Door Receipt w
Will the applicant or future building occupant store.,handle hazardous material r�
m defined by the Cape Tina Municipalend Cade,Chapter 9.12, the Health and Safety HEATING UNIT(OVER I(q,IXXI BTU) TOTN,:6
Cale,Seedion 255320)7 VENTILATION FAN(SINGLE RESID)
❑Yes *No
Will air
applicant s building by he use Are.
Quality
Mwh igerna t
BOILER-COMP(3HP OR 100.000 HTTH ISSUANCE DATE
hamNoua air contaminates as JeDneJ by the gay Arca Air Quality Managemem BOILER-COMP(OVER I00,000 BTU). 11!��District? A I D
❑Yes � NEW RESIDENTIALMECII. SQ.IT. IC
I have read the hazardous materials requirements under Chapter poa of the JUL 9199 �
Culifn hal mad&Safetyrdous Sections25505,ement and25534. Iter 6.9 of that
if the building does not currently have a terwnt that it is my responsibility,to notify the
occupant the requireme t Priorm issuance.(a Cc ,, de.!
G 4 CITY I w
(ner r authorized agent am TOTAL: ISSUED BY'
OFFIC