25464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOR tLjH11(j-hilh.UrR1 AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 25464 A
BUILDING DIVISION BUILDING PROJECT IDF.N'I'BF'ICAT'BON L J C n of 4
BUILDING ADDRESS: //✓/J /J SANITARY NO. APPLICATION SUBMITTAL DA'TE
2���✓ �J�� W✓C UNIT# LOT#
OWyEy,NAM / PUONCI
CONTRA 'OR'SNAME: LIC NO:
5.// ' I37� _ NIC CON9'ROI.#
• RCHII'ECIENGINEER: LIC NO: ADDRESS: ❑
CON'TA 1': PHONE: BUILDING PERMIT INFO
CITY. ELECTRIC PERMIT FEE
73537 BLDG LEC' PLUMB MECII
PERMIT ISSUANCE
El El
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RESIDENTIAL
pal Ihereby affirm that l am licensed underprovisions of CTapter9(commencingwith 1 DESCRIPTION
+100 fallSection final)of DivlsionJnf the Business anJ Professions Code,and my license is in PANELS
f'✓F- PollfnrceunJeffect.
FLK W
IA License Clens Lia# UP T03x1AMP5
y 6 d Dam Cocaine 201-1000 AMPS
F-yz ARCHITECTS DECLARATION OVER 1000 AMPS SG.Fr.FLOOR ARTA 5/SQ.FT.
O Z—G 1 understand my plans shall be used as public records.
r y t W SIGNS ELECTRICAL.
<y2[j Licensed Professional
zy LL'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
%O L I hereby,affirm that 1 an exempt from the Conuactor's License Law for the
W 3 LLy¢ following reason.(Section]031.5,Business and Pmfcssions Cade:Any city mormay TEMP.METER OR POLE INST. I )
F�c s] which requires a perm t In construct,aper,improve.demolish,or repair any souaure
5n>-;g prior to its Issuance,also requires the appl icant for such permit m file axigned statement POWER DEVICES
,m<C, thatheislicensedpursuamm theprovisions ofthe Contractor's License 1,w(Chapter SWIMMING POOL ELECTRIC I,LL,aoT 9(comtnencing with Section JIXp)of Division 3.fmc Business and Pmfessians Code) V LU Md_'1
,2a, or hei3eempttherefmmand the basis the alleged
exempion Any violation
f
4N S,tion701.5appicmnfar.pemnrsimpese ,beara civil penafty.f OUTLETS-SWITCHES-FIXTURES
Q not more @un rive hundred dollars WWI.
$= NEW RISIUENTIAI.I:LELTR _SQ.FT.
dace ❑ Las stock,
spcdy.ormyemenyecswithwed for
safei(sole compensation, I'1?CON,�TRUCI'ION
i3— and pr teework,ande: he Coeisnot inroicerocawdoess1apply to C4.Business J
and erty who
Code:The Contractors License Law does oat apply to an owner of
propenY who builds or improves thereon,and whodoea such work himsdforthmughhis
r,mployccs.pmviJed tM1:n xucM1 improvements arenmimended oroffemd forsale.IT. DEC.GROUP RES UNITS
however,the buildingor improvement is sold within one yearof completion,the owner- T
builder will have the burden of proving that he did not build or improve for purpose of 50
1c QTY. PLUMBING PERMIT FEE FLOODZONE APN
I.asownerofthe Sec.70,l. exclusively an Premiums
with licensed Cmanvmtrams to
t suuct the project(see ,ata ro,ofaa and ywho sioos Code)mime The Cem,and
hiansc l.uw,Joeanot upplywun ownenrf przapmy who M1uilJs orimpmvee lhere0n,and PERMIq'ISSUANCE
whocmmmets for such projects with a conimctor(s)licensed pursuant more Contractors ALTER-DRAIN&VENT-WATER(CA) FEESUMMARY
License Inw.
❑ I est exempt made,Sec. ,B&P C for this reason BACK BLOW PROTECT.DEVICE SIDE FEES
SANITARY YN
n D' s RECEIPT#
DRAINS-FLOOR,ROOF.AREA.COND,
•
covers WORKMAN COMPIiNS IONDECLARATIO SCII001.'I'A% Y N
❑Worke
rs'
affimtthalhave a orti ecaeoRonumm.f(Secum,0r Lob CL)ate ofwhich FlXTURIS-PFA TRAP RECEIPT'#
covers al Cmployee's nituunnttrmit. fled copy thereof(Sec.3800,1,eb CJ which PARK FEE Y N
rs AI employee's under this pcmait RECEIPT#
Y GAS-EA.SYSTEM-1 INC.6 OUTLETS BUILDING DIVISION FF.IS
Polley p
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCI{IiCK PEE
❑ Certified copy is bercby famished.
❑ CertifiNmpy is fled with the city irepecti0n division. GREAST•jINDUSIRL WASTE INTERCEPTOR GRADING FRE
CERTIFICATE OFEXEMITION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Tlti,ecubm need not he completed ifthepernth is Perone hundred dollars($1100) SEWER-SANITARY-STORM It.20011. ENERGY FEE
or I..)
I certify that in the performance of therwork for which this permit is issued.l shall WATER HEATER WIVFNTELECTR
not employ any person in any manner ao as ss��IT the Workers' PAID
Compenaainn l�,aaqq,,,,�afCallIna�..��A�D,�tt s" WATER SYSTEM/TREATING Date Receipt#
0 z Applicant Ll/i1_ "SYi3f S/ 7'J��
Z NOTICE TO APPLICANT:If.after making this Cenificoe of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
^ becomesubject to the Workers Compensation Provisions of the Labor Cade,you must BUILDING TEE
a > forthwith comply with such pmviaions or this permit shall b,deemed revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC ITE
a. I therebymfimt that there is a construction lending agent or the rfmccamoe of
U O I. My ,e.t,,.:.. p` TOTAL: ELECTRIC FEE
the work for whir,ht t '�L'Jaj�' C.
Lenders Name rnn L PLUMBING FEE,
4' F Lenders Address QTY. MECHANICAL PERMIT FEE
L1 I certify that 1 have mad this Application and state that the above information is MECHANICAI,FEE
>s L1-I correct. Iagrcc mcontply with all city dndcountyotdinances and state haws rclatingto PERMH'ISSUANCE
F-' 0. buildingeonstrunlon,andherchyauthomempmsenutivesofthiscitytoenteruponNe CONSTRUCTION TAX
V z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hantless the City of Cupertino against
Iiabilities.jam,mensc costs and expenses which may in any way sector,against said City ABR HANDLING UNIT(TO 10,000 CPM)
in Ime gra ' fth1, y t.
wnms co' soh. �/ /� AIR I I ANDLING ON IT(OVER 100)(1 CFM)
Signatumof App�MContracmr (/~� /tee EXHAUST HOOD(WNUCI') PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Receipt#
Will theopplicua nr more buildingnocupamamenr handle hay.ardous material HEATING UNIT LOVER 0000,(100 B'rU) l-
ar demes d by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crtd,Section 25532x)? VENTILATION FAN(SINGLE RFSID)
ElYet, ,�No ISSUANCE DATE
Will thexppllwm nrlaurcbuildingoxcupam useeyuipmenmrdeviceswhichemit BOILER-COMP(}hIPOR 100,000BN)
haard0us air conmtninarns as defined by the Bay Area Air Quality ManagementBOILER-COMP(OVER 1W,IXN1 BTU) RECEI VED,l
• District'( CI
Yes �Nn NEW RESIDENTIAL M[CH. SQ.FT. AUG 18
Qll
1 have read the ha'eurdous materials requirements under Chapter 695 of the 19] 1
California health&Safety Code,Sections 25505.25593 and 25534. 1 understand aha
ifihe building docs not currently have a tenant.Na it is my resp0nsibilityto notify the CITY, OF,�ICUPUTJ
occupant of mr,ir rcme I IN h mush` t prior to ixsuenee of o C mfiea of
g�3
Onsnerm-nalminzed.g,it / Diac TOTAL: ISSUED BY: