25060 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOe L 1 .h.,rRICA I. PERMH NO, n C {^�
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 O 6 O
BUILDING DIVISION BUILDING.PROJECT mENTIVICATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
4j..f. UNIT# I. Tit S�
O NFRSN E. PHO NTRACTOR'S NA I,IC NO:
J - T S • a N/C CONE OL#
RCI II ECTIENGINEER: LICNO:•` DRI S1A S72 . El
3
,TNTACI': PHONE: BUILDING PERMIT INFO
QTY, ,, j ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
y.Z I herebm
yaffirtba,lam licenseuro
dnderpvisnn
iaof Chapter)(commencingwi,h
00q S«tlon700shOfDlvleioa30flhe Bautiossud Professions Cade,and my license ie in PANELS n /(�/'
a�JU full force ade� `'Y/ (4-c/l
fQ„ZW Licen« Lic.# w UIPTON)BAMPS v
m1—M. Date Com SD 201-LINO AMPS
Z8yF ARCHITECT'S DECLA O OVER IWAMPS .Q.PI'.FLOOR RIS S/SQ.PI'.
1 amemm�d ter Trona anwl be aced a.panic m«atria. �'�j ' J
�yF SIGNS ELECTRICAL
�y�J License)Professional
yd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaF 1 hereby affirm Na,1 am exempt from the Contractor's License Law for the
3v-y following reason.(Section]031.5.Business and Profusions Code:Any city or county 'I'EMI'.MLTOl.fi INST.
taO; which requires.permit ht customer,Mar.improve,demolish,mrepair any swcmm
.EN}�
print o its issuance,also requires the applicant for such fermi,to file a signed statement POWER DEVICES
p
that he is licensed pununano the provisions of the Contractors License Law(Chapter
aaoz 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION /I
p_Io or that he is exempt therefrom and the basis for the alleged exemption Any violation of —yo a
FZY
Section]031.5 by anyapplicam force permit subjects Nenpplicanno o civil penalty of OUTLE'"S-SWITCHES-FIX9'ORES
$SC not tome him five hundred do]].($50B. NEW RfSIDGNTIAL LIECIR _SQ.Ff.
9F� [11,asownerorthepropeny.ormyemployeeswiNwagesm Neirsolecompensation, . ORIES TYPE CONSTRUCTION
will do the work,und the snucture isnot intended orolfered llnsale(Sec.7)44,Business
and Professions Code:The Contractor's License Law don not apply In an owner of
propenywho buildsoTlmprovestheomer.and whodres such workhireelforlhrough his F A-L-.=
G 11 INTI"
ownempmyees,proviJest,ha,such improvementsme no,intended toff mcd forrale.If,
however,the building orimpxwemem is sold within one yearofcomplction.theowne. .TOTAL: ® IV /1
builder will have the burden of proving that he did not build or improve for purpose of �\V/'
colo.). *PLOMBINGFERMIT❑ I,as ownernfthe pmpeny.amexduaively contracting with licensed canwemrs toQTY. - PGEFu3oD zoNl N
!�construct the project(Sec.]059,Business and Professions Cade:)The Contractors PERMIT ISSUANCE WE
Liccnae Luwdocn oat apply to nn nwn«ol property wM1obuilJc orimproves Nmeon,enA
whocoaineN for such projects with a cormorants)licensed moment lothe Contractors
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this rcaonIIT. ,MEN
BACK PLOW PROTECT.DEVICEOF
YN
Owner Uma RECEIPTp
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N_
❑ Ih.bent'Co affimt Nall Insurance
ora ecamof copytherof(Sceure,o.a bC.)w which
RIeCEII'T#
FIXTURES-PER TRAP
Worken'Compensaion lmunnce ora certified copy Nerrof(gtt.38W,Lab CJ which PARK EEL Y N
rovers ell empbyee's under this permit GAS-FA.SYSTEM-1 INC.4 OUTLETS RFCEIP1'p
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4 HA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASILINDUS9RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASLTRAP SOILS FEE
COMPENSATION INSURANCE
Misutionne noiMcompletedif,hepermitis foronehand«ddollan(5100) SEWER-SANITARY-STORM HA.20017. ENERGY FEE
orless.)
I certify Nnl in floe,connareeofmhe wmlliruwhich,hispermmsissued,l shall WATER HEATER W/VFNT/EL1?CTR
no,emplo y person in any using
ere m bac '«t m the Workers PAID
Co.pensa f `✓Dam WATER SYSTF.M/IREATING Date Receipt If
Z Applicant a�� f'T/IIf°m l?'T�'
zNOTICE TOAP ICANT:If.aRermekmg this Certificamof Exemption you should NEWRFSIDENTIALPLMB. SQ.IT. TOTAL.
Prq become subject i e Worker's Compensation provisions of Ne Labor Code,you must
a ; fonhwi( h comply wiNsuch provisions or this pemtit shall he deemed revoked. BUILDING I7I7E • OO
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 1 hereby affirm that there is a construction lending agency for the performance of
U O the work far which this Permit is issued(See 3097,Civ.C.) TOTAL: ELECTRIC ME
w Lender's Name
Lender's Address QTY. :_MECHANICALPERMIT a THE PLUMBING hEE
U I certify that I have read this application and state that Ne above information is
correct.I agree to comply with all city and county oNimaaces and state laws relating in PERMIT ISSUANCE MECI IANICAL FEE
Ln buil ding construction,and hereby authorize representatives of this city to enterupoathe CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
ngr«m eavq indemnify and k«p harmless Ne Cimy of Cupertino against
Iia limier juJgmm�a,rosasa rpenseswhich may inanywuy¢closs geins,said City AIR HANDLING 11NH'(TO IO,gNI CFMI
in uen¢of the gran gof lis permit.
AIR HANDLING UNIT(OVER 10,000 CPM) ('��
Sig rarepPliaa
canVCom� m D e EXHAUST HOOD(MIDUCT) PAID) 3 Q
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Receipt#
Will the ppllc ,or future building occupant store or handle hamrdous materiel HEATING UNIT(OVER 100,000 DTD) 'TO TA
rti3a 0
as defined by,he Cupeno Municipal Cade,Chapter 9.12,and the Hisilth and Safety
Cade,Section 25532(.)"ANm
VP.N9'lLAT10N PAN(SINGLE RPSID)
C Yes
Will the applicant orfumrebuildingwcupant useequipmenwrdaviceswhich ami, p
BOILER-COMP OHP OR 100,(0(BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10TOD)BTU) T A ,
Ibionat?
❑Ycs frMNn NEW RESIDENTIAL MECH. SQ.FL
I has read the hazardous materials re drements ander Chapter 6.95 of,he MAY 111993
Cal"I'm
11 thin&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the b Idi does not camently ve a moan,,Nnl it is my res sinility m notify Ne
encu o the requirements ¢b m�(stMmet priormissuan idi if¢anof �II I vF UUl[Its IINV
Owner ora Nod ngem D m TOTAL: IgSUIiD BV� �� VlIT
OF