25255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD;1.-alk:CrRTCA. PERMIT NO. /1 1�I1/� r
APPLICATION/PERMIT PLUMBING-MECHANICAL / ^ / /
BUILDING DIVISION BUILDING PRO.IRCT IDEN'TIFICAT'ION L V L L V
HUILDING ArD�D�RPSjS: , SANITARY NO. APPLICATION SUBMITTAL DAII'.
Or_J LJ z UNIT» LOT» It �
O S PHON': C RACfO Mli: AIVNO.
/C CONTROL
• F.CFN'
ARCHITT/ GINEER: LICNO: A 0.' Min Wl� El
COm'AM: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING.PERMIT INFO
BLDG ELECT P E
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Matz I hereby ofOrm than l um licaued under pnvisionsofChapta9(commencing with JOB DESCRII'1'ION
IV OO Saninn]1XItl)of Division3of Nc Business and Professions Cod and my license is in PANELS ^ /��
C I+l I1— full force and effe �C�1/
VT3 / UPT02WAMPS
F Z W Liccn lass Lic.»
F?H Dute Contactor 201-1000 AMPS SQ.IT.FLOOR AREA W.FT.
'LO,Z ! CHITECPS DLCLARAT OVER IOW AMPS
OZ-0 1 undersand my Plans shall IN,used as public records.
ted SIGNS ELECTRICAL
QN�j Licensed Professional
W,x< OWNER-BUILDER DECLARATION SPECIAL CIRCUUMISC.
n'Oa V 1 hereby affirm )lot I um exempt from the Convectors License law for the
I Say following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F tS O which ta,a ms a permit n construct,after,improve.demolish,m repair any aouaum
5 n priono in.issuance,else requires thenpplicatt fa such permit mElea signed samment POWER DEVICES
ouC O p Na he is licensed pursuant to the provisions at the Contractors License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
auto 9(contmencing with Section 71)(10)of Division 3 of the Business end Professions Code]
=rn nn but be is cxempnhaefmm and the basis fm maanegedevemption.Anyviolaumnf l
F.Z Section 7031.5 by troy applicant for a permit subjects the mPplicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
�_ not mom than five hundred dollms(5500). NEW RESIDENTIALELECTR _SO.FT. STORIES TYPECONSTRUCI'ION
KL ❑ I,asownerofthcpmo ay.ormyemployaswithwaguwtheirwlecompensauon.
a3°2 will do the work,and the strucare is not intendedoroffcred fmtatc(See.]044,Business
and Prr)l'acslOns Cale:The Contractor's License Law docs not apply to an owner of
pmpeny whobuildsnrimproves Nereonnnd who does,mch wnrkhinoelfmducia,hhis OCC.GROUP RES.UNITS
wnemployms,pnvide4t atsuchimpmvcmmntsar notimendedmofferedforale.If,
however,the buildings improvement is wldwid in one yearafcompleuon,theowner- T
builder will have the burden of pmving that he did not build or improve for purpose id
sale'), QTY. PLUMBING PERMIT FF.E FLOOD ZONE APN
❑ 1,avownerof the properly.mnexclusivelycontmetin"ith memadonnvncmrsm
onswa the Project(Sce.7044.Business end Professions Code:)The Contnemr'e
License Law does not applyto anownerofproperty whobuildsorimpmeas thereon,and PERMIT ISSUANCE
whocontrnes fssuch innocent with aconuacmr(s)licensed pursuant to the Comments
License law. AI:fFR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 sen exempt under Sec B&P C for Nis rctrwn OUT SIDE PEES
HACK FLOW PROTECT.DIiVICE
SANITARY YN
Owner Dem DRAINS-FLOOR,ROOF.ARF GOND. RECEIPT»
•
covers WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have acenificum ofconsem mself-insure.or a certi0com of FIX7URES-PI7R TRAP RECEIPT»
Wska,,Compensotion lnsuremcmnu cenifmd copy thereof(Sec.381),Lab C.)which PARK FEE Y N
nolle 1 Ri GAS .SYSTE INC.4 OUTLETS RECHIPTp
Pol cya /(�.mw BUILDING DIVISION FEES
Company lama/'a+`� GAS-EA.SYSTEM-O 'R 4(FA) PIANCHECK FEE
❑ Cenificd co hereby furnished.
Cenificd copy it fled wiN the city inspenina division. EASEpND0 R1.WA'TE INTERCEPTOR GRADING Iddi
CERTIFICATE OF EXEMPTION FROM WORKERS' SET SOILS ME
COMPENSATION INSURANCE
rlbis semionnad not Ce completed if Ne permit ix fm one
did (SIW) E -SA)H1'A Y-S RMEA.2WFT. ENERGY FEE
late.)
I certify that in the performance ofthe work for which this permit is wed,Ishall WA H TCR W/V,NTELECTR
not employ any person in any manner as to becoom subject t Ne Worker' PAID
Compemation Laws of Ctlifomia Date so TF�SYSIV' EATING Data Receipt#
zZ Applicant
2 NOTICE TO APPLICANT:If,after making this Certificate of Exacrom ou. uW ESIDENT LPLMB. SQ.lef. TOTAL:
F-' y becume subject to the Wohof's Compensation provisions of Ne Lahr Cod euro
forthwith comply with such provisions or this permit shill t<domed mvok BUILDING FEE
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby admitted is o construction lending agency for Ne perfmmanc f
U O TOT ELECTRIC FIiIi
0e work for which his d them.it is Issued(Sec. len Civ.O.)
rr Lenders Name PLUMBING PEIi
O"' t' Leader's Address TY. M ECIIANICAL PERMIT FEE
U I certify that I have read Nia application and sum that dm above information is MECHANICAL FEE
>" LL7 cooed l agree m comply with all city and county ambulances and state laws mlating no IT ISSUANCE
I" N building construction,and hereby authorize represenailvcs of this city m enter upon the CONSTRUCTION TAX
U Zalwvcmcmiond property for inspection purposes. ALTER OR ADD TO MECH
ra
(We)#gm save,indemnify and keep harmless Ne City of Cupemino against
.. Iiabilities,judgments,costs and capcmea which may in any way«crueagaimt said City AIR HANDLING UNIT(TO IO.OWCFM)
m ,�yDenccO
n n f the m ' this permit.
,G AIR HANDLING UNIT(OVER I0,00n CPM)
S.,Outof Applica.VCu /V agar a^•�•---/ Data EXHAUST IIOOD(W/DUCT)
mPAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IWAW BTU) Dole Receipt»
W illnthe applicant or tams.building occupant store s handra hazmdous material HEATING UNIT(OVER 100,000 BTU) TOTAL.:
as defined by the Catania.Municipal Code,Chaim,9.12,and the health end Safety
Code,Seiors 25532aU VENTILATION FAN(SINGLE RESID)
❑Yes leNo
BOILER-COMP(JHP OR IW,WOBN) • ISSUANCE DATE
Will the applicant or furore defined by thenBay Area Arn Quality
c MumagM1 turn
ncethazardous air cnnmminund as,dcfired by the Bey Area Air Quality Management yOILER-COMP(OVER IIXI,(XNI BTU)
• District:'
LJ1 p
Yex e!J No NEW RESIDFN"f1AL MECII. SQ.FT. P % I D
I have read the hazardous materials requlremema under Chapter 6.95 of the
Calilifmin health St Solely Coca,Sections 25505,25533 and 25534. 1 undersand than
if the building does not currently have a tenant,that it is my mspunsihility m notify the APR 11
« p f t mlw,m�^emy. A t be a prior to Issuance of a Cenificam of
°`jf�G�Y,pa y—i/-9i ISSUEDBY� '' U (
Ow amnmmcd asap Data