25279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO r �I' PERMD'NO'
APPLICATION/PERMIT PLUMBING-MECHANICAL. !] n
BUILDING DIVISION INIIAING PROJECT IIIF:N'1'IP'ICA'I'IfIN G L
BUILDING ADDRESS: /1 SANITARY APPLICATIONPI
APPLICATION SUuBmi' 'AL DATE
7 rpJkK
^ ,\ tL bow Dy�P • UNIT LOT is
G AME: PHONE: CONT ACfOµ/'S NAME: /.,/ LIC NO: `���•
K - [(,L(.L VI(l / (Q SAN 3 �z2� NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADD ESS pf—
q ,f�fs, leas ft e ,Z4P
CONTACT. PHONE: k BUILDING PERMIT INFO
LLECTRIC PERMIT FEE
1� e 5 - - BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OWz I hereby affirm that l am licensed underpmvisionsofChapter9(commencingwilh
1900Section 7030).1 Division 3of,ha Business and Professions Code.and my license is in PANELS ♦ ��
WZw torenoJeffo
FZW Ln, e- cyn g Iicq Zr UP T0200AMPS
mD mcr 201-1000AMPS
Do
Z OU° ARC]IITECTS LARATION OVER I"AMPS
SQ.FT.FLOOR AREA $/SQ.PT.
O z�O 1 undersand my pl ell be yyyyyyssssssW lic aid 6 SIGNSELECLRICAL
L¢enseJ Profasaianal
W W Q that
I a. B exempt
from
DECLARATION SPECIAL CIRCUIT/MISC.
OaU 1 hereby all ion thm 1 am exempt from the Contactors License Lew for the
W 3 tz-rFit following reason a(erection co3L5,Business and Professions Cade;Any city or county TEMP.METER OR POLE MST.
0� which regnireaapemsno connruct,apar,nt forsuchfewia t file repair
gnedany
statucmre pOWERDEVICES
C�Q� prionoits issuance,also requites the applicant fonuch permiuo Bim signed statement
W W p0 that he is licensed Eamon nt to the Provisions of the Contractors Liam.Luca(Chapter
LXOAl 9(commencing with Section 70(10)of Division 3 ofthc Business and Professions Cade) SWIMMING POOL ELECTRIC I VALUATION
aided he is exem t therefmm and the basis for the aIle ed exem t M 1 t f ^,
W—m p g pion. yvioeiono OUTLETS-SWITCIiES-Fl 1V
l.-z,Q Secti.n703i.5by.y.,Iicentf.,.permit,ubj..,h,.pplic.ntmsci,il,.n ti,.f
not more than Eve hundred dollars($500). NE•W RFSIDEM3AL ELECDt S IES TYPE GQNSTRDQ7QN
C o ❑ I,oowncrofthepmpeny,ormyemployceswithwagesasthcirsolecompens.tion,
y3o0 willdo the work,and the structure isnot intended oroffereAforeale(See 7044.Business
and Professions Code:The Con recto's License Law does not apply to an owner of
property whobuilds orimproves thereon,andwbodoresuch work himsclforthroughhis OCG GROU THIS.UNI'T'S
eon employccs,providcJ ohm xuchimprnvemrnts arenotintendcdoroffered forsele.If,
however,the buildingor improvement is sold within one year ofecmpletion,the owner- TOTAL: -
builJer will have the buMen of proving that he did not build or improve for purpose of
IC, ti. .. . .. -p.,
sale). QTY.d PLUMBINGPERMIT Fl?I: FLOOD zoeE AFN
❑ Ius awncnd'Ihe pmpeny,o xcluervelyconvacungwubliccnseJ cnntrecmrvl rye, Ip.
ousWm the project(Sec.70W4.Business and Professions Cud,The Gmtmctor'sLicense Law duce not apply loanownerofroperty whobuildsorimproves thereon,and PERMIT ISSUANCE
who contracts mrsuch projects with acontracmr(s)licensed pursuant to the Convector's DRAIN WPA
- ATER
License Law, ( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B ffi P C Por this re.aon BACK PLOW PROTECT.DEVICEOUTSIDE FEE
SANITARY YN_
Owner Data DRAINS-FLOORROOF, RECEIPT#
, , . .
WOR KMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ Ihereby.Mmthailhaveacenificateofcmn ntmmif-insum,or.ccnificateo( RECEIPT#
FIX'IVItES-PER TRAP
Workers'Compensation Insurance oraceniFiW copy thereat(Sce.3800,Lab C.)which PARK FEE YN
A
H all empbyee's under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy 0 BUILDING DIVISION FEES
Company GAS-BA,SYSTEM-OVER4 TEAT PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ CeNRed copy is Bled with The city inspection division, GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPHON FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompletedHNe petmitis foroae hundred dollar($HIO) SEWER-SANITARY-STORM EA.200FU ENERGY FEE
or less.)
I certify that in the performance afthe work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as m become subject m the Workers' PAID
Compensation Luwsof C.limmus. Date WATER SYSTEMfrREATING Dam Receipt#
0 z Applicant
z C) NOTICE TO APPLICANT:IL after making this Cmifirmeof Exemption,youahould NEW RESIDENTIAL PLMIL SQ.IT, TOTAL:
Lo become subject to the Worker's Compensation provisimLv ofthe Labor Code,you must
a 5' forthwith comply with such Provisions or this permit shall be domed marked. BUILDING FEE /a
W (❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm That them is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Lender's Name y, ,
0 U Lenders Address QTY;, 'MECHANICAL PERMIT PEE PLUMBING FEE
1 really that P have read this application and state that the above information is t
>" W correct.l agree m at
comply with all city and county ordinances and se laws relNng to PERMIT ISSUANCE MECHANICAL FEE
f' Ln building construction,and hereby authorize representatives ofthis city toenterupnn the CONS9RUCTIONTAX
U z above-mentioned propcny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap his--desfe City of Cupertino against
Imbilities,judgments,cos.and expense whir any way seerve against said City AIR HANDLING UNIT(TO 10,000 CFM)
inc n. enceaftb ing of this
AIR HANDLING UNIT(OVER 10,000 CFM)
Signaare of AJpI icam/ ounsctor EptacT I EXHAUST HOOD(W/DUCT) PAP])
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOB,Wt)BTU) Date Receipt#
Will the applicant tit more building occupant store or handle hazardous material ❑fiA'1'ING UNIT(OVER 100,01D)BTU) 'f01'N:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the IIcahn and Safety
Code,B.Cll El Yes ❑No
23592(.)4
❑ YEN'HLATION FAN(SINGLL RESED)
BOILER-COMP(3HP OR 100,100 BTU) ISSUANCE DATE
Will the appicunt or futurebuilding occupamuse equipm<madevices which emit /^�
hazardous #03,000 BTU)air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER# BTU) r 13p
District4 aM I
Yea 11 No NEW RESIDENTIAL MECH. SQ.IT. �•_ O
1 have read the hazardous materials requirements under Chapter 6.95 of the 4` (! _
Califomi.Ilealth&Safety Cale.Sections M505,25533 and 2 5M.I undcrsand Nm `s
if the builJing Aare nm cumendy heveetenant,Char it is my msponsibility to notify the II
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. I
Owner err authnnizcJ agent Dam TOTAL: ISSUED BY: