25063/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1UU1.iA I i- LLUTIUCAJ PERMIT NO,
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL
NUILDING PROJECT IDENTIFICATION 5 O C
J U
BUILDING ADIL%%BSS'S'�`: ,A .I--�al- 11F t�/,q1k SANITARY NO. APPLICAATIJONSUBMITTALDATE
— C1 A `\l V\ UNITN LOT#
O S NAMIi: I Q p11pNE: `� CON'TRACTOR'S NAME: LIC NO: N/C CON9'ROLM
Lxw�
ARCI IITECTIENGINEER: LIC NO: ADDRESS: ❑
[ONI'ACr: PHONE: q - - HUILDING PERMIT INFO
QTY„,rd_d a y Lr+LBCTRIC PERIvI7T,.1- FEE,
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE Sd d IGT Kl El
LICENSED CONTRACTOR'S DECLARATION APPWANCES-R&SIDENTIAL JOB DESCRIPTION
Ipyz Ihereby affirmthat l areicenutdonderpmvisionsof Chapta9(commencingwiN ...k I
00❑ Sadiron 7000)of Division 3ofthe Business and Prfesamr,Cade,and my license is in PANELS �� I b �+�Vq4a1
a�lJ full have and effect. 11” �C-
<Z, License Class Lic.It UP TO 200 AMPS
y Q y Date Conmutor 201-1000 AMPS JA'r4j
20r`rn� ARCHITECT'S DECLARATION OVER I"AMPS SQ.IN'.FLOOR AR $/SQ.FT.
oz-0 I understand my plans shall be used as public mentis.
M SIGNS ELECTRICAL
WcenveA Pmfwsional
iK OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �rD
NXaOgF I hereby affirm that 1 am ewmpt from the Contractors License taw for Ne
:twma Mllowingrceo,(Section 7031.5,13mcir ssand Pmeraiws Cade:Any cirymemuity TEMP.METER OR POLL INST.
C J which se9uim a permit to consumer,alrtq improve,demolish,or repair arty structure
;Fnm Prior to itskwmce,also requbesmeapplicaat rmmch permit to file.signedsmmment POWER DEVICES
E2 that he is licensed pursuant to the provisions of the Comommes License law(Chapter
ta.is. '9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMINGPOOLELECTRIC VALUATION
,My or he,he is exempuherefmm andthe basis for lhealleged exemption.Any vtolationef
4 Section 703 1.5 by any applicant fur n permr a pen
it subjects the applicant civil alty of S, OUTLETS-SWITCHES-n% RES O)`'
I ore than five hundred dollan($500).
W F_o baseone..flheproperty,mmyemployceswith wageaesdoirmlecempaoNEW RISIDENTIAL ELECfR S .FT.aticn, Q RIES TYPE CONSTRUCTION
lldnthe work,andthesuucrure is not intendedoroffered for sale(See704L Business
and Professions CWe:'ne Commeter's License Law does not apply to an owner of
property whobuildsmimprnestmew,and whodosa meh workhimselferthmugh his
own employees,providedthat such improvements we notinteadedoroffered formic.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearo'vompletion,the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las theaonhepniSec.7 am Business
and mmaiions Code:)
Theommcmrsm ,
Construct the oes ad pply loanW.
Baseness and Professions Code:)The Cereen,a d
License Lawdoes notapply tn.n nwnerof progeny wM1obuildsorimprnvesthereon,end PERMIT ISSUANCE 0
whocontracls for such projects with a Commentfs)licensed pnrsumuo the Contmerors ALTER-DRAIN&VENT'-WATER LEA) O FIile SUMMARY
Lic
❑ I u e pt under Sec. B ffi P C for this reason BACK FLOW PROTECT.DEVICE UTSID; E
r —� -- SANITARY Y N
OwnewD DRAINS-ROOR,ROOF,AREA.GOND. RECEIPT#
WORKMAN COMPENSATION D LARATIO SCHOOL TAX YN
� ❑ Iherebynffinnthutlhavmrcertifiomcof canscntto self.lnsum,on cedlliomenf .f7� RECEIPTIt
Workers'Com FIXTURES-PER TRAP
penaetionlmuhis Per ecrnifmd copy thereof l5aJg00,Lab CJ which PARK FEE Y N
coven all anployee a under permit. GAS-CA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION PFifiS
Company GAS-EA.SYSTF-M-OVER 4(EA) PLANCHECK ITIS
❑ Certified copy is hereby famished. J.]
❑ Cerifiedcopy is filed with the city inspection division, GREASFJINDUSTRL WASTE INTERCEPT OR GRADING FEE,
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not beconniAmdiffhepermit is feronelmndoed dailies($pXd SEWER-SANITARY-Sl'ORM F.A.200P1'. ENERGY PEE
or tem.)
I certify that in the perfonoware of the work far which this permit is issued,l shall WATER HEATER W/VC
not employ any person in any manner so a to become subject to Ne WorkersPAID
Compenmtionlawso(Califomia. Date WATER SYSTRMIIRRATING Date Receipt It
zC)Z Applicant 3� D
NOT ICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENT IAL PLMB. SQ.PT. TOTAL:
t•-' (q become subject o the Workers Compensation provisions of the labor Code,you must 1
� ? forthwith comply with such provisions or this permit shell la,domedl revoked. BUILDING FEE Od
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEL' g S�
z 1 hereby affimr that hem is a Consumction lending agency for the perfonnance of
V O the work for which this permit is issued(Sec.3097,Civ.CJ 'TOTAL: d_�� ELECfRIGFTC 3
Lenders Name
U. PLUMBING nsE
F Lender's Address QTY, MECHANICAL PERMIT FEE - d
U 1 certify Char 1 have mad this application and state that the.hove informwion is
>s 1 correct.l agree to comply with all city and county mdinances and state laws relating to PERMIT ISSUANCE MECI IANICAL IEE
E-' In building commuctioa,and hereby authorize representatives ofthis city to enter uponncc
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECIi. CONSTRUCTION TAX
tom- (We).gra w save,indemnify and keep harmless the City of Cupertino against
res rt 'udgments,rosts and expert swhich may I..my way acerueagvnst said City AIR HANDLING UNIT(10 10,000 CFM)
in w segs ncc of the grunting of t
5- // AIR HANDLING UNIT(OVER 10.000 CPM)
Signa oro of ApplicanUComtnanr arc EXHAUST HOLD(WMUC)
PAID
HAZARDOUS MATERIALS store SURE
BEATING UNIT(TO 100,000 BTU) Date Receipt#
Will that)in C.am or fumrc building occupant erre or handle hazardous d material
az defined by rhe Cuperinu Municipal Cnde,Chapter 9.12,and the lleallM1 and Safely I IIFATING UNIT(OVER I(kl,ll(I(113'fU) TOTAL: Z
Code,Section 25532(a)7
❑Yes x No VEM'lLAT10N PAN(SINGLE RLSID)
ISSUANCE DATE
Will@ea li<ant orfmurehuildin ruse BOILER-COMP(3HPOR 100,0110 BTU) ,
pp goecupen equipmenmrdevices whichemif �k
I hazadous air Contaminants as defined Ay the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
urricft a[
❑Yes K-U. NEW RESIDENTIAL MECa SQ.Pf.
1 have read the hazardous materials requirements under Chapter 6.95 of the MAY 111993
l'tomM Heulrh&Sefery Coda Sections 25505,25537 and 25534. 1 understand Nor
ifth whingdoesaotc.men0y atenamJhm it is my msponsibiliry to notify Ne
cepa of dm twain.'was w C e ast Ic met prior to issuance of a Cert'nate of
coup 3 Oft ur�uurena Btu
r or amherimd ugen am IOTAL: ISSUIiD BY:
i
•• 1. r t r � I 1 •.
07