25318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ING-RLRCI RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25318
BUILDING PROJECT IDENTIFICATION
BUI/ I}
LLDDINCakDDREIS: 5 r� ,s1 01-z� SANITARYNO. APIM.ICATIONSUBM117ALDATE
1 `e IK/ ryv.r) d rev! Q MIT J, LOTH 'aweB1
O ER NA F: /^D aa-_ ,I VE: 1 CONTRAS SJt _� LIC NO: NIC C`ONTROLp
�l `fill /PN VN ..R. V LIC INO: ` ADDRESS: \`t^s+�_•l ❑
CONTACT: �- PHONE: i BUILDING PERMIT INFO
(((,,,,,,,,, (7� ,s QTY, ELECTRIC PERMIT IEE
IY/f(/�7y�/')�S D BL lk/rdpignELECT PLUMB MECII
_�(ID �I/ I PERMIT ISSUANCE
LILENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ED El
LOB DESCRIPTION
419Z I hercbyaffinn that lam licensed underprovWmaaef Chapter 9(commescimg with
Poo Section]IXq) dDivision 3 of the Business and Professions Code,add my license is in pANE1Sfull
qZ
License
nseClafirace nc(fea UP TO 200 AMPS S t
QQ License Clad Lic,p J
m<y Date Cantr C 201-100M AMPS
zOyZ. ARCIII'TECFS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.Fr.
OZ-G ]understand my plans shall hated as public records.
records.
SIGNS ELECTRICAL
6�Yn,,j Licensed Prrfcesiosal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. •.�R
5a5�'OyU 1 hereby aRrm that 1 am exempt from the Contractors License law for the O'Y
tr13Orn follswir'nowon.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. /
rn J which requires a Permit to construct,alter.Import demolish.or repair any structure fT
fp2Y$ prior to its issuance,also requires the applicant forsuch permit file a signed statement POWER DEVICES UIVa
y W G p that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter —
L 9(commencing with Section Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
ow' (c gwi ) LUA'1'I N
_y or that Sectiohelsea mpt by
therefromandfor
basPermit subjects
tstheddempti to civiny l Penalty of J
gaetion903 LS by any applicant fora Permit lnbjaets the applicant mscivil Penalty of GULLETS-SWITCHES-FIXTURES
F� ¢ pt no than Bve bundtcd Jollun(5500).
Wit$ I,esowner MthcproKry,ormyemployeeswithwagesastheirsolewmpensation, NEW BE P.LECIR _SQ.FT. STO TYr ECONSTRUCfION
L - ill t work,nnJ the structure is nrtimenJedorolfared Tortola(Sec,9044,Business M�/
and Pmf ions CMe:The c(mmo tuts License law does not apply to an owner b(
property who buildsorimproves themon.and whodoessuch work NmselforRwugh his
employees,pmvided Nm suchimprovemeneem not intendedorofferedforsole.Jr. OCC.GROUP - RES.UNITS
however,the building or.improvemem is sold within one yearofeampletion,the owner-
builder will have Ne burden of proving that he did not build or improve for purpose of TOTAL:
le.).
❑ Ldownerof the propry,unexclusively contractingwith licensed amirdem.1. QTY. PLUMBING PERMIT PER FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions CudeJ Tire Contractors
License Law does not apply to an owner of popery,who but[&or improves thmeart,and PERMIT ISSUANCE
who concocts forsuch projects with a contractor(s)licensed punuunuo the Contmemrs ALTER-DRAIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason ' IDL FF.
BACK FLOW PROTECT,DEVICE. SANITARY Y N
Owner DataRECEIPTM
DRAINS-PLOOR.RGOF,AREA,CONO.
WORKMAN COMPENSATION DECLARATION SCIfOOLTAX YN
Iherebyaffmm that 1hovea or
Corti a copytherof(Sns......ab C.)which RBCF?1PTM
workerv'Com FIXTURES-PER TRAP
Pensetien lrtsurencanreceriFial copy thereof(St,e.Jg00.Lab CJ which PARK ME Y_N
ars all empinyee's under this permit. GAS-EA.SYS'T'EM-I INCA OUTLETS RECEIPT p
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 HIAA) PfANCHECK PEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GRFASEdNDUSTRL WASTE INTERCEPTOR GRADING LLE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETIAP SOILS FET:
COMPENSATION INSURANCE
(This sectionneedtam becompleted if the Permit is forest,hundred dollars(SIM) SEWER-SANITARY-STORM EA.2o0FT. ENERGY LLE
orless)
Tcerifyflat in the performance of the work for which this permit is idued,]shall WATER HEATER W/VENf/ELECIR
not employ any Person in say manner an us to become subject to the Worker.' PAID
Compdsallomlaw9of Califomia, Dae WATER SYSTEMINUR TING Data Receipt#
O z Applicant
Z 0 NOTICE 1.0 APPLICANT:If.after making this Cerifcare of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) become subject to the Workers Compensation provisions of the labor Code,you must
> forthwith comply with such provisions or this Permit shall be daemon revoked. BUILDING FEE �a
0. A CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm tharthem is a construction lending agency for the performance of
O the work for which this Permit is issued(Stat.3097,Civ.C.) TOTAL: ELECTRIC FEE
w r Lenders Name
C�.-J+ Lender's Address QTY. MECI IANICAL PERMIT PEE PLUMBING Mr..
]certify that I have mad this application and stare that the above information is
0. cmmct.]agree mcomply with all city and coumy oNinancea and nem lows relating to PERMIT ISSUANCE MECHANICAL FEE
h buildingconstmedon,and herebyauthoricerepresenudvaof this city toen¢r upon the
V above-mentioned property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTIONTAX
(We)agree to save,indemnify and kaep harmless the City of CuPertiro egaina
liubilities,judgmengants and enPe set which may any wayaccrueagainst said City AIR I IANDLING UNI'1'HT010,000 CFM)
avormodrelacc of the8 ting of th prtnii AIR I[ANGLING UNIT HOVER 10,11X1 CFM)
{��Il
'igdatu Applicam/Co mactur Data EXHAUSTHOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Rcccipt N
Will the applicant or future building occupant store or hurdle hazardous material
re defined by the Cupenimn Municipal Code,Chapter 9.12.mad the Health and Safety HEATING UNIT(OVER I MOM BTU) TO
Cale,Section 25532(n)7
13 Yes ❑No VENTILATION PAN(SINGLE RESID)
/a Will the applicanterfnumbuildingacuprm usecquipment ordevices which emit BOILER-COMP UHP OR IM .BM BTU) ISSUANCE DATE
hmaiDBI, loct? 0,000 r9 air contaminants ns defined by theA.Bey AAt,Quality Management BOB
DistrLER.COMP(OVER 10BTU)
i
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT.
1 have rend the huraNeus materials mquiremems under Chapter 6.95 of the N�
Califomia l lealth&Safety Cade,Sections 25505,25573 and 25534.1 understand thmoccupa
if the building eros not curromly hate a stnam,mat it is my responsibility ter notify Not of the rtm
quirtemh a which must met prior toissuanceissuanceof a Cmificute of
OcO'c
Ocemuncy.
Owner or authomred agent Date TOTAL: ISSUED BY:
OFFICE
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