25475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBINGMECHANICAL
BUILDING PROJECT IDENTIFICATION
25475 J4JJ
BUINCADIRESS: SANITARY NO. APPLICCATIONSOULBMM
ITTALDATE� IN UNIT# LOTp
O FRS i: PHONECONT CRAMLIC NO
Dp -'saw�
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ARCHITECDENGMRER: LIC NO: ADDRESS
_ oa h �Si
CONTACT: Pxorve: QIr 11 TY,
xri. EPEEaCRReaEsHU417NO PERMITINFO'
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El ED 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL BOB DGSC IPfION
py�Z Thereby Division
arratdefile sed Business
andvisienso...Chile,and
my Beene,
with /],A � /0
zF�i 00 Scclion]OW)of Division 3oflhe Business and Rofessions Cade,)(c my wa I. ppryBlg Illb✓MII'_ pGJ
=,4 fullfome end effect. 3
dgana IiW Gonaector �� �� UPTOS 00AMP
Noy
Lee
N �' V U
Do
Z F8 v ARCHITECTS DE IO OVER IOW AMPS SQ.FT.FLOOR EA $/SQ.FT.
OZ-0 I understand my plans shall be used as public records.
W 6SIGNS ELECTRICAL Licensed Professional
we": OWNER BUILDER DECLARATION SPECIAL CIRCUF/MISC.
X3 W F 1 hereby affirm that I am exempt from the Contractor's License Law for the
fallowing reason(Sermon]031.5,Business and Rofessions Code:Any city or c...ty TEMP.METER OR POLE(NST.
which acquires a permit m consunn,alter,improve,demolish,or repair,any svnctum, -
N� prior to its issuance,also requires theappreant forsuch pc.Ill.file.h Igualmdumnd POWER DEVICES
WO p that he Is Vacated pursuant to the i mvidin s of the Contractor's License Law(Chapter
d� 9(atmmencin with Section Division 3 orihe Business and Prafessleos Code o�y gwl ) SWIMMING POOL ELECTRIC I VALUATION
�_,y or that 7031 51,
I mom
the permitenbe tsthedexemant to civilp malty of OUTLETS-SWITCHES-FIXTURES 1 /�—
are"on)03n by anyapplmcan.for a($11).it subjects the applicant to acivll penalty of I 5-0 00
ronot more than five hundred dollars($5 W). NEW RESIDENTIAL ELECTR 5 ✓I
❑ the wrk,anhepropenure is memployedoro eregesasth,(Smecompensiness Q TORIES TYPF.CONSTRUCTION
witch the work,ands: structure a Connector's
endederofw down not (gly to an Business
and Professions Cale:The Contrad.r a License Law such
out apply if an owner is
own ertywhobu pdsarimprovesthemprove wtashe nsuetandedmmsdfor forsalhhis DEC.GROUP RES.UNITS
wt.employees,provided that such improv let wit are not intendedproffered for Bale.If,
however,the
avete burden
of ementissolde didnone year ofcnoroveion,for the purpose of TOTAL:
bumidm will have the burden of proving that he did not build or improve for purpose of
sole) "•
❑ = PR '? , PLUMBING
FLOOD ZONE APNI,mowner ofthe property,amexelusively contracting with licaneedmimmato oQTYE
construct the project(Sea 9044,Business and Professions Cade:)The Contractor's PERMIT ISSUANCR
License Law doesnot apply manowerrofpropeny whobuilds mimpmeasthercon,and
whocontmea forsuch projects with a eonvelodo licensed pursuant to the Contractor's ALTER (EA)
License Law. -r F88 SUMMARY, „
❑ I am exempt under Sec. ,B&P C For this reason BACK FLOW PROTECT.DEVICE N }v OUTSIDE EES
SANITARY Y N
Owner Dow DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION S OOL TAX YN
• covers❑ (hereby affirmthatlhave.cenificute ofconsem tolelff-irmea,marenificateuf RRCEIPTN
Workers Com FIXTURES-PER TRAP
poyee'snierthis Permit, ifed copy thereof(Sec.38W,Lab CJ which PARK FEE Y N
all employee's under this penult. �{�1 GAS-EA.SYSTEM-I INC.4 OUTLETS RECEirr#
Policy# VV II BUILDING DIVISION FEES
Company FUJI' G
❑ Certified copy is heretiy u al lied GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME
Candied copy is riled with the city inspection division. GREASEUNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE _
(This sectmonneednot bacon fated iffoe permitma foronehuntheddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
or less.)
I certify that in the performance ofthe work for which this permit is smad,I shall WATER HEATER W/VENT/F.LECTR
not employ any person in any m racer so as to become subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTEMITREATING Dale Receipt#
0 7-+ Applicant
z NOTICE TO APPLICANT:If.arm,imaging this Certificate o'Exemption,you should NEW RESIDENTIAL PLMIU SQ.FT. 'TOTAL:
E-I H become subject to the Workers Compensation provisions efthe Labor Code,you must
La. forthwith comply with such provisions or this permit shall be Deemed revoked. BUILDING FEE 3s'—
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
rte- z I hereby affmt that there I,.construction lending agency for the performance of
U O the work for which this pmmh I.issued(Sec.3099,Civ.C) TOTAL: ELECTRIC PEE
(1. p Lenders Name v.
O t-' Lenders Address QYVy.T4,�$V ;M�CIIANICALPPRMIE } ' is 3',rFEGti PLUMBING FEE
U I can fy that I have read this application and state that the above information '"" -'
correct.l agree in comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building connotation,and hereby malurizerepresentatives ofthiscity to enter upon the - CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree mime,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any wayaceme again tsamd City AIR HANDLING UNIT(TO 10,000 CFM)
in roc,aence the I`ttnng pf t s arm I
'(II '^`I AIR HANDLING UNIT(OVER 10,00)CFM)
4igrundo'Applicant Contractor I Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,WO BTU) Data Receipt#
Will the applicant or future building occupant store or handle meanders material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)P
0Yes kNo VENTILATION FAN(SINGLE RESID)
,
Will the epplirnnmrPomrebulldingoccupam useeyuipmenmrdeviera whiehemh
BOILER-COMP UI IP OR 100,0011 BTU) ISSUANCE DATE
hazardous air contaminant as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID D
Dishio? �o A
El NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the JAN = 1994
California lleahh&Safety Code,Sections 25505,25533 and 25534, 1understand that
if the building does not currently have a tenant,that it is my responsibility m notify the
cupant of there ems hie met be mm nor 0 is...m f a enificute of
OOeetpene - 0 ) �A e OF c f Lh i ll:xJ
Owner or Imairrrest.gem I Date TOTAL: ISSUED