25463 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mm:nlNr.RIFCTnrcA. PERMIT NO.
APPLICATION/PERMIT PLUM IIING-MECHANICAL C �I [g
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION' J 4 U
BUILDING ADDRESS: /�� 1 , /r C SANITARY NO, APPLICATION SUBMITTAL DATE
IV lrME �/T2� OtL-L A C112—CoL4%JIT, LOT# V Y
OWNERS NAME: PHONE: CONTRACTOR'S NAM^ LIC NO: NIC CONTROL#
JLLAl`fjl"A SIMP)e W-S nt. 1
ARCI III Ea7ENDINEER: LIC No: ADDRESS: ❑
gas- ag9-7
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Oe'Z. Iherebyv'Divixasl was 3 ofth Business
and isionsoonox Goer and mmencine with _ ^ �—
c00F Seaionereby Affirm
Division 3af thesed nde and isionssiota Code. poomy namiuvewa in PANELS
, U full forceamd effect.
fa-Zw Licenu Class Lic.# UP T0200 AMPS
vf?y Dam Crouse r 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.IT.
�yy ARCHI'1'F,CTS UT:CIARATION OVER 1000 AMPS
—
OZM Iamai:smid my plans shall bcusNas publa,mcords.
F eJ SIGNS ELECTRICAL
<'KG licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X06 V I hereby affirm that I on exempt from the Contractees License Law for the 11 I
u 3 a n following recon(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. 9� 666�E�
H LL C) which requires a permit to construct,alter,improve,demolish,or repair any structure zt s.�
ft�>- prior to its issuance,also requires the applicrnt for such pemuuo file a signed slnemem POWER DEVICES a J,GI ICS
QJ 0 that he is licensedumantrnothe provisiom ofthe Contractor's License Lew(Chapter
aae� 9(commencing with Section 700o)of Division 3afthe Business and Professions Cade) SWIMMING POOL ELECTRIC
1ATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
,Zy Seami
bn7031.5by a,applicantfora pertsubjcc.,hevpplicanuoacivil penaltyof OUTLETS-SWITCHES FIXTURES DATE---------
not tre then foe hundred dollars($5 W). FT.
C'Cp% avnwnetofthcproperry,ufmyemployecswuh wages as theirsolecompenmlion,
NEW RESIDENTIALELECTR SQ. STORIES TYPE CONSTRUCTION
tothe work,and the structure is not intended or offered for sale(Sec.J044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
owncoywyiecs, dovidedruvesthereon,andwhnidoessuchworkhroffie orthrside.Is
awn employces,providedthat such improvememsarenorimendedorofferedforsNe.If., OCC GROUT' RES.UNITS
h vwcvcf,the building or improvement is sold within one year ofcampletion.the owner. O
builder will have the burden of proving that he did not build or improve for purpose of
laic')' QTY. PLUMBING PERMIT FEE
❑ Lar nwmrofthc propcny,amadusivdycontmcting withliccnud cmnwcmrs to F100D yONTi APN
contemner the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law docsom apply loan ownerefproperty whohuildsorimprovex,mrso n.and PERMIT ISSUANCE
whocommctsforsuch projects wilts mmractnr(s)licensed porsuamm the Conwcmr's EA ALTER-DRAIN&VENT-WATER
License Low. (EA) PEE SUMMARY
❑ I ain esempt under Sec .B&PC for this reasonTSIDE FEES
BACK PLOW PRECT.DEVICE QI'
SANITARY YN
Owner Date RECEIPTp DRAINS�FLOOR,ROOh,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I] Thereby affirm thatlhavcacenificam of content to ulf-insole,oreanificatanf FIXTURES-PER']RAP RFCHIPI'#
Workers'Compensation harmonic ora terrified copy themof(Sec.3800,Lab CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 TEA) PLANCHECK FEE
❑ Ccnifcdcopynhercbyfumideed.
❑ Certified copy is Filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not becomplered ifloe permit is future hundred dollars($100) SEWER-SANITARY-ST ORM EA.200FT. ENERGY FEE
or lcssJ
I certify that in the performancc ofthe work for which this permit is issued,Ixhall WATER HEATER W/VIJJT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
CompcnaaEonlvwsof Califomb. Dam WATER SYSTEM/1'REATING Dam Receipt#
O Z Applicant
z0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F V) became subject m the Workers Compenmtion provisions of the Labor Code,you must
7 forthwith comply with such pvins sioou permit shall be deemed revokai. BUILDING FEE
ro
W Q - F.
i CONSTRUCTION LENDING AGENCY SEISMIC FE
z I hereby affirm that there is a construction lending agency for the pctformance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sea.3097,Civ.C.)
W Lcnder's Name PLUMBING FEF,
Lender's Address QTY. MECHANICAL PERMIT Flifi
U 1 certify that 1 have read this application and state that the above information is MECHANICAL ITH
correct.I.,.to comply with all city and county ordinances and sure laws relating to PERMIT ISSUANCE
V) building conswction,and hereby nuNorim representatives ofthis city memerupnn the CONSTRUCTION TAX
(;J z oMwe-mentioncd property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,cosmand expenses which may inanyway secure against said City AIR HANDLING UNIT(1010.00)CFM)
in conseyucnne of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
of Applicant/Cmumaor emn EXHAUST HOOD(W/DUCT) PAID
HAFARDOUS MAIERIAIS DISCLOSURE HEATING UNIT(TO ImLIXNI BTU) Dam Rcccipt#
Will the applicum or future building nccupam store or handle hazardous m
mcri°I TOTAL:
as defined by the Cupertino Municipal Cost,Chapter 9.12,and the Health and Safety HEATING UNIT(GVIiR Im1,OW BTU)
Code,Section 25532(x)1
CI Yes ❑No TIVENLATION PAN(SINGLE;R2NID)
Will theapplicantorfuturcbuildingoccupant owequlpment ordevices which emir
BOILER-COMP(3HP Oft HX J000 BTU) ISSUANCE DATE
haeardous air contaminants as defined by the Bey Area Air Quality Management BOILER COMPfOVER 100.000 BTU) q /
istrict7 a'i
❑Yes ❑No NEW RFSIDEM'IAL MECH. SQ.FT. {�S�DIII
I have maJ the hazardous amen.ls eequimmems under Chapter 6.95 of the 41JG 1
Cvlilitmet Health&Safety Code,Sections 25505,25533 anunderstand
d 25534. 1 that
n �s/� Y
il'the building Joos not currently have a moa ,that it is my responsibility to nobly the (f
xCip:ml fir the requirements which most he met prior m Isaaance of a Certificate of Ul' `sf 0M
Occupancy. V
lryv
Owner m authorized agent Dam TOTAL: ISSUED BY: