25995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .;rRx.EecTR PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25995
BUILDING DIVISION j BUILDING PROJECT IDENTIFICATION ;
BUILDING ADDDRRsESISS rv,' SANITARY NO. APPLICATION SUBMTITALDATE
{-0 6txq sckw LOT# xiiir'�
OWNS S PHONE: CI G LIC NO:
N/C CONTROL#
I'MCTIENGINEER: LIC NO: �f[) 1-t
6-7
'ON'I'ACI': PHONE: "'" E: C ) 9 r:•'T>
_ BCTRIC PERh1TT""" ".�x. ' aFEEx"BUILDING-PERMIT INFO
BLDG ELtlCf PL G
PERMIT ISSUANCE
BLDG
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
QWZ Ihereby affirm that l am licensed underprevisions of Chapter9(commencing with
iW Op Section 7000)of Division 3 ofthe Business and Professions Cade,and my license is in PANELS I�A
RUW C full force and effect. UP TO 200 AMPS D wu_�
FZai License Class Lic.#
m6y Dam Contractor 201-1000AMPS
lz o 7 ARCHITECT'S DECLARATION OVER IfIW AMPS SQ.PI'.FLOOR �$[Sp.yq
O'Z•,O I understand my plans shall be used as public records. ^(
SIGNS ELECTRICAL • l F
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O4F 1 hereby affirm Nal i am exempt from the Contractor's License Law far the q C�s L
1+130 m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR FORE INST.
V4 which requires a pemtitto consumer,alter,improve,demolish,or repair any structure /�/. 1
NQS promo its issuance,also requires Ndu � V{/
e applicant for such pemo file a signed statement POWER DEVICES
y1� C that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter T
9(commencing with Section 701007 of Division 3 ofthe Business and Profeseions Code) SWIMMINGFOOLELECTRIC VALUATION
W!2 or M1eisexempt
any of
n,f the basis Permit
subjeallegedexemption. civiny l
of OUTLETS-SWITCHES-FIXTURES ^ �
Section 7031,5 anyappllcdlforapermitsubjects the applicant meeivll penalty,of L \J
not morethan rofhundreddollars yemp. NEWRESIDENTIALELECfR _SQ.FT.
❑ l,aso.thew k,rundtproperty.orm no,
EnsureiSee.compensation, STORIES TYPE CONSTRUCTION
q willdothewark,ande:The dureisnm imendense La a does not
apply to son Business
and Professions Code:The Contracmra License Law does not apply w an owner of
limparris
owneywyees,psmimprovesthennirriaridmprevewbodoesstimmidkMmselfonhrough his OCC.GROUP RES.UNITS
employeesilding or improvement
provehimprovementhin me year
ofidoroffered the ale.own If,
huilder r.wtheavet a burden of ementissold withinoneyear ofrnmple for
eowner-
builder will have the harden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,mnexclusively contracting with licensed contractors to QTY. sPLUMEING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)Use Contractor's PERMIT ISSUANCE
License Law does not apply a sn owner of pmpeny who builds or improves Hereon,and
who contracts forsuch projects with scarification)licensed pursuant to the Contractors
License Law. gLTER-DRAIN&VENT-WATER(EA)
- FEE SUMMARY
❑ 1 arra exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-PLOORROOF,AREA, I RECEIPT#
.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I harabyoffirm that l have aeerificate ofcousearro self-insurgoracerificateof FIXTURES-PE TRAP RECEIPTN
Workers'Compensatinn Insurance oraccnifiedcopy thereof(See.3800,Lab CJ whish PARKFEE Y N
acr,co,rdl employee's under His permit. GAS-EA.SY II .4OU TSOF is RECEIPT#
Policy# lhtIIIVISION FEES
Company GAS-EA.SY r 4(EA) PLANCHF.CK
CICertified copy is hereby fumishsd.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRI. STE INTERCEPTOR GRADING kE ,.✓'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF
COMPENSATION INSURANCE
(This section reednm becompleted lffieparmids foronehundrat dollars($10d) SEWER-SANITARY-STORM EA.200M. ENERG
less.)
I certify that in the performance of the work For which this permit is issued,I shall WATER HEATER W/VENT/FLECfR
not employ any person in any manner so as to become subject a the Workers' PAID Pit
Compensation Lawsof California. Date _ WATER SYSTEM/TREATING Data RarTOTAL:
Z Applicant
O 0 NOTICE TO APPLICANT:If,after mCaffeine r aking this Certcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.55 becamesubjectto the Workers Compensation provisions of the Labor Code,you must> forthwith cumply with such provisions or this perritmall be deemed revoked - BUILzCONSTRUCTION LENDING AGENCY SEISM
✓✓R (hereby aflinn NHere at is ecnnstrunion lending agency for Hnn
e Performance of
U 0 the work for which this permit is issued(Sec.3091,Civ.C.) T ELECTRIC FEE
Lenders Name PLUMBING PEE
U Lenders Address QTY. . 't TD1ECHANICAL PER MIT - + xPEE
1 certify that 1 have rend this application and stem that the above mfmmuno F'r
acorrect. l agree to comply with all city and county ordinances and sate laws relating in PERMITISSUANCE MECHANICAL FF.E92 Ift
building construction,and hereby authonee representatives of this city to enter upon the CONSTRUCTTON TAX
U Z above-mentioned r oes. ALTER OR ADD TO MECIi.
�6yu� S SIC
(We to s qty of Cupertino against
liabilif ,j end expens mxyin any way accrueagainsteaid City AIR HANDLING UNIT(TO 10,00)CPM)
gran permit.
�K..# AIR HANDLING UNIT(OVER 10,000 CFM)
Si, Dete EXHAUST HOOD(W/DUCT) PAID
HAZARD SMATERIALSDISCLOSURE HEATING UNIT ITO 100,000 BTU) Date Record#
Wil I the applicant ter tutu a building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 25532(a)p
❑Yes El No VENTILATION FAN(SINGLE RESID) IQ I
Will the applicantorfumrebuilding occupant use eyuipmenmrdevices whichemit
BOILER-COMP QHP OR bill"BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER
-COMP(OVER 100,000 BTU)
District^ g� A B 0
❑Yes ❑No � NEW RESIDENTIAL NIECE, SQ.FT. T
1 have read the hazardous materials requirements under Chapter 6.95 of the pq�� 2,9California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
into building doe,amt currently have a tenant,that it is my responsibility to notify the
cup of He requirements which must be mar prior issuanceof a Certifeam of
O fa',...
Occupanan cy.
L 11lV(J
Owner or authorized agent perm Vnf6f4, ISSUED BY:
OFFICE