25646 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILD( G-ELF.Ut RICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2
C C /1 C
BUILDING PROJECT IDENT'IF'ICATION G J v f� o
DING ADDDRRESS: SANITARY NO. APTT
/PLICAON]SUBMITTALDATE
/0'O 11"lI�A UNIT# LOT
OWNIi NAM' _ PHONE: CO R'S NAME: LIC NO: {{{ •'
OWWG-/ Y
NIC COM'ROLp
ARCHITECI'IENGINEER: l LICNO:NO: A%
CONTACT: PHONE:
QTY. ELECTRIC PERMIT ME BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCN
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
pyy I hereby affirm that l am licensed underprovisionsofChapter9(commencing with JOB DESCRIPTION
ltaCC Section 701 Division 3 of Ne Business and Professions Code,and my license is in PANELS force end effect.
License Class Lu.It UP102MAMPS
y G a Dale Commemr 201-(000 AMPS
Fy" - ARCIIITECTSDECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
ZOw0 Iunderstandm hall to used as public records. OVER IIXIO AMPS
OZ.❑ my p .-
Pn ; SIGNS ELECTRICAL 1 a
Q LicensedProlessimal T' ® I A� I
E: OWNCR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. l 9 V
KOy V 1 hereby affirm that I amexempt from roe Contractor's License Lew for the C^s
tsl'30o~i followingmason.(Section l031.5,Business and Professions Cade:Any city mecum, TEMP.METER OR POLE INST.
1_'tSy� which requires apennimro contra".alter,improve,demolish,or repair any swnure tV 0 II 1
��Y7 prior to its issuance,alsorm,ires the applicant fmsuchpemduo file a signed statement POWER DEVICES / Q
W W G O that he is licensed pursuant to the provisions of the Commences License Law(Chapter
a%oCC 9(commencing with Section 7W)of Division 3 ofthe Rusimas and Professions Code) SWIMMING POOL ELECTRIC
WM, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OIITLEI'S-SWITCHES-FlXT11RFS
Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
z3� t more then five hundred dollars($501,. NEW RESIDE- AL Q ELECTR S .FT.
ElI,asownerofthepupeny,ormyemployaswithwagr astheirwlecompensudon. STORIES TYPE CONS'TRUCT'ION
willdothewmk,and the structure isnotintendedoroffercd forsal<(Sm.7(akl Business
and Professions Cole:The Contractor's License Law does not apply to an owner of
property whobuildsorimprovesthereon,and whodoes suchwork himadforthrough his OCC.GROUP RE'S.UNITS
ownemployees,provided that such improv entsarenotintendedoroffered forsale.If,
howe er,thehuildingor improvement is sold withinoneyear ofecmpletion,the owner- TOTAL:
builder,will have the burden of proving that he did not build m improve far purpose of
sown
crofthc property.omexclusivelycontractingwith licensed contractors In QTY. PLUMBING PERMIT FEE FLOODZONE ql'N
constr cl due project(Sea.9044,Business and Professions Coda)The Com......
License Lawdoes not apply to un ownerofpro,any whobuddsor improves thereon,and PER 755UANCC
whoemormis fdsuch projects with a monetarist licensed pursuant o the Comment's gLTER-URAPR(
L#&VENT-WATCA
License Law. ) FEESUMMARY
❑ 1 am exempt under Sm. ,B&P C for Nis remon BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date RECEIPTp DRAINS-FLOOR,ROOF,AREA,CO
• ND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherchy affirm thatlheveacenificete nf<ornemmr to self-insure,arse ecnificsm ofRECEIPT#
Warkers'Compensation lnsumnce oracenified copy thereof(Sa.3800,Iab C.)which IgX'TURfS-PER TRAP PARK FEE YN
covers all employee's under thisL RECF.IPTN
Pe^nm GAS-FA.SYSTEM-I INC.4 OUTLETS Policy p BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenifieJ copy is hereby famished.
❑ Certified copy is filed with the city impaction division. ORIIS ANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE,TRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseninnnced nmhecumpletedifthepermilis forodehunlmoldollars(Shr SEWER-SANITARY-STORM EA.2001"T. ENERGY FEE
or less.)
I mril'yflut in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Worker' PAID
Z Compensation Laws of Culil'omiu. Date WATER SYSTEWMEATING Dam Receipt#
0 O Applicant
NOT ICE TO APPLICANT:If,after making this Certificate of Esemptian,you should NEW RESIDENTIAL PLMEL SQ.IT. TOTAL:
fq become subject o the Worker's Compensation provisions of the Labor Code,you must
FFFa"' forthwith comply withsuch provisions or this permit shall be deemed revoked. BUILDING FEE
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I herehywifoor thatthem is a construction lendingagency for the Nofimmanceof
the work for which this permit is issued(Sm.307.Civ.C.) TOT ELECTRIC FEE
Lender's Name PLUMBING FEE �-
O F Leader's Address QTY. MECHANICAL PERMIT FP13
V I certify tbar I have mad this application and smte that the shove information is
correct.L agree to comply withal]city and county drdmances and store laws relating to PE-WIT ISSUANCE MECHANICAL FEE
F' buildingcomtruation,and hemby atubsoe representativesa(this city to enter upon the CONSTRUCDONTAX
V Z above-mamboed properly for inspection purposes. ALTER OR ADD TO MECH.
(We)ag to uve,indemnify and keep a City of Cupcnino against
It bilines.' emacmta anJexpenses which may y way accrues einstmid ity AIR HANDLING UNIT(TO 10.000 CFM)
ce of the granting 'thi. it. AIR HANDLING UNIT(OVER 10,000 CFM)
Ignmbr of Applicvn4Cont or., pat EXHAUST HOOD(W/DUCt)
PAID
HAZARDOUS MATERIALS DISCLOSt HEATING"IT(TO 10),0100 BTU) Date Receipt It
Will the applicant or future building occupant stare or Sid1rho,mckar,malarial
as defined by the Cupertino Municipal Cole.Chapter 9.12.and the Health and Safety 11EATING UNIT(OVER 100,000 B'N)
Cale,Section 25532(e)'1
El Yes ❑No VENTILATION FAN(SINGLE RESID)
ANCED E
Will the applicant rfmurceq
building occupentuseuipmenmBOILER-COMP(3HP OR 101,0(X1 BTI]) ISP
rdeviceswhich emit A � q
haxwJaus air cnnlaminams as defined by the Bay Area Air Quality Management BOILER•COMP(OVER I00,OW BTU) N
Dinrici?
Cl Yea ❑No NEW RFSIDENTW.MECII. SQ.IT. e y1
1 hove read the haaan ous materials requirements under Chapter 6.95 of the • Zs'/��� 19 wA7a/
California I Health&Safety Code,Sections 25505.25533 add 25534. I understand that V
if the building does not currently have a tenant,that it is my respomibility to notify the f CUrth 111��
occupant of the"ttirements which most be tun prior to issuance of a Certificate of
Occupancy.
Owner m authorised agent Date TOTAL: ISSUED BY:
OFFICE