25987 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RoLoloIN�ELECTIdTCA1, PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25987
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: //� SANITARY NO. APPLICATION SUBMITTAL DATE
4. . Nirr / LOrx lQ
R/fJAML: PITONFFY�L�����
CONTRA(TOR'SaNA E: LIC NO: _ I 1•
// / c+lJ ✓ ✓ s/ /� n ? ' NIC CONTROL#
ARCHITECT GINGER: LIC NO: ADDRESS: / ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nyy Ihereby affirm hat l am licensed under provisionsorChapher9(commencing with JOB DESCRIPTION
H400 Section 7000)of Division 3 ofthe Business and Professions Cale,and my license is in PANELS
<- full force andeffe . UPT0200AMPS
Qjt ficcnscands aLie,M TTT 111 ��_
,<0- Umc Comrxctor 201-IM AMPS SQ.IT.FLPR AREA $/SQ.FT.
y7- pS
ARCHITECT'S DECLARATION OVER IM AM
'GO
O0'O I understand my plans shall be used as public records.
1 L,i. W SIGNS ELECTRICAL
6 5_I Licensed Professional B
ayY.C� OWNER-BUILDER from
mEC Contra ON SPECIAL CIRCUR/MISC. I 6 !�
WO o, I hereby affw tion 1 am exempt from the Gonion is License Law for the (3 /J
O`F° following unres a.(Section to Contr,Business and Professions Cnde:Any city or county TEMP.METER OR POLE INST. 111 a�OJ IIhJ Il`(hl
which mymres n perms to constrvct,el¢r,improve,demolish,or repair any swnurc
}� prior to its issuance,also requires the applicant f«such permit o file.signal Montreal POWER DEVICES
K 00 that M is licensed pursuanno Ne provisions of the Conewror s License law(CMpnr SWIMMING POOL ELECTRIC
9(wmm0)of eade,with Section]00Division 3 if the Business and Professions Code) t
orthat he isexempa themmumand thebasisforthe alleged exemption.Anyviolmanof -,J1
tZ4 Section]031.5 by nnyopplicoufor.lenniladjeco,the applicant macivil penaltyof OUTLETS-SWITCHES-FIXTURES
z'y'y not mom thin live hundred dollar,N500) NEW RESIDENTIAL El.IIR _SQ.FT.
Fo ❑ Lthewrk,andepropeny,ormyempindedorrofwal for sale sole compeasafien, STORIES I'YYIi CONSTRUCTION
will do thewon%Cedmc he Cummins is License Law
rot applyXec0044.Business
wall Professinnz code:The Camrxror's License Law does not epPIY to an owner of
property who bui Ids or improves thertou,and who does such work h imsel for through his
own employees,provided that such improvemesanot intendedoroffcrtd formle.If, OCC,GROUP NFS.UNITS
mt,
however,the building or improvement is sold within one year of completion,thc owner- TOTAL:
builder will have the lumen of proving that he did not build or improve for purpose of
sale). PLUMBINGPERMIT FEE APN
❑ I,asownerofthe property,am exclusively contracting with licensed contractors contractorsto QTY.
crancruci the projm(Sec.70F4,Business and professions Cale:)The Contractor's
IicennaLaw does not applymanownerafpropeny wholowidamimproves thereon.and PERMIT ISSUANCE
who Common for such projects with acoawctrut licensed puramon to the Contractor's
License law. ALTER-DRAIN&VENT-WATER(EA) FEF,SUMMARY
❑ I=exempt under Sec. ,B&PC for this reasonSIDE FEES
BACK MOW PROTF.CI'.DEVICE
SANITARY Y N
Owner Dan DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT
• cu WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
FI
❑ Ihereby affirm thetl haveaunificmc o(conunt to xlf-insurt,ora eenificmc of XTURES-PER TRAP RECDP a
Workers Compensation lnsursn«ora«nifiedeopy themof(Sec.3800,Lab C.)which PARK FEE Y N
coven all employ«'a under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS - RECEIPT'#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenined copy is fled with the city inspection division. GRE-ASEINDUSTR.WAS'I INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
Mix section need not be completed Blue permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM PA.201 ENERGY FEE
or less.)
I eciify thin in the performance nflhC work far which this .it is issued,I shell WATER UPATER WIVFNTp3LECTR
not employ any person in any manner so as w become subject to the Worker' PAID
Compensationl-swsof Califomia. Dao WATER SYSTEM/TREATING Dan Receipt#
zz Applicant
O NOTICETO APPLICANT:If,after making this Certificare of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
become subject to the Workers Cumpensauon provisions of the Labor Code,you must
1Y fnMwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
SEISMIC FEE
❑
CONSTRUCTION LENDING AGENCY
.J. z Ihereby forwhih that isocon (Sec.3lendingagency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.309'1,Civ.CJ
Isnder s Name PLUMBING FEE
W F Lenders Address QTY. MECHANICAL PERMIT FEE
V 1 certify that I have read thin.pplication and sten thus the above trimmed.is MECHANICAL ME
>" W Connect. l.grte to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby autburxC repmsentatives ofthiscity to enter upon the CONSTRUCTION TAX
V z ulnwc menllnned property fauspeel npurposes. ALTER OR ADD TO MECI I.
(We)agree set save,indemnify and keep barmlesa the City of Cupertino.,.last
liabilities,jodgraenb.cosn andexpenus which may in any way accrueagmist said City AIR HANDLING UNIT(TO 10,"CFM)
sego ce of the grenfing.fthia permit.
AIR HANDLING UNIT(OVEN 10,000 CFM)
M
ignat eof Applaan ontmctor - Date EXHAUST I IOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA]INC,UNIT(TO too,00013'TU) Don Receipt N
Will the...heart or future building oecupam store or handle haMardous materiul
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER 100.000 BTU)
�>
Cale,S«tion 25533(.)? VENTILATION FAN(SINGLE:RF31D)
❑Yea ❑No
ISSUANCE DATE
Willthcupplicum nrfuturcbuilJing«cupant meeyuipmemurdevi«swhicb emit BOILER-COMP(JHP OR 10),000 BTU)
husanlous air Cnntweinam,m defined by the Bay Arco Air Quality Mun.gemenr BOILER-COMP(OVER 100.000 BTU) Bq
• Uistricrt tY p ! pT
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.IT. N Y LL!
I have read the hmurdous materials"Moments under Chapter 6.95 of thede. VAN
n pr 1
California Health&Safety CaSenium 25505,25533 and 25534. 1 understand that k� N
i f the but lding does not currently have a tenant,that it is my respemibllity m notifythe s ep
ccupon of the requirements which must he MCI prior to ksuance of a Cer ificate of CI)
Ocwpancy. Lt VI
Owner or authmind agent Date TOTAL: ISSUED BY:
OFFICE