25578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDIN,-P1LF.;I RACAL PHRM1"T NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n C C p
BUILDING PROJECIADKNT'IFICA'1'[ON G J J O
BUILDING ADDRESS: I,y SANITARY NO. APPLICATION SUBMI FLAL DATE
• UNITA- e LOT# / 4
WNERS NA Lt: COLIC LIC NO: l
NIC CONIROLM
tl CUTE. pibIGINEER: -LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
11 DO ELECT PLUMB MECIi
PERMITISSUANCE 0 0 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 DESCRIPTION
QCZ I hereby affirm that l am licensed underpmvisions of Chapar9(cammencing with �\
�00 Section 7DW)of Divison 3 of the Business and Professions Code,and my license is in PANELS { ✓v
yZ firall Liecow Cladeffect. t
ff Liccnsc Class Lio.M UPT0200AMP5 -.S✓ l��']4—�D� I�i�sl(-,V—�{II_3J.5`�'�i
rnQ Date Contractor 201-1000 AMPS
Z O,Z ARCHD'ECTS DECLARATION OVER IOW AMPS SQ:FT.BOOR AREA f/SQ.IT.
0-L'-�Q I unaerimnd my plum,mIl he used as public reran,.
P ti F�2 SIGNS ELECTRICAL
Liao,ed Professional
�C6 OWNER-BUILDER DECLARATION SPECIAL CIRCU I'I'/MISC.
°�OyF I hereby M.mat I am exempt from the Commerce,License Law far the
µ1'3LLy followingmaupn.(Section 70315,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
01which requires a permit In construct.niter,improve,demolish,or repair any structure
T� #Apra its ixsmmm.also rtyuires thenppliem,ficrouch pemtit to filensigned statement POWER DEVICES
p0 that be is licensed pursuant to the Provisions ofthe Commnlm's License Law(Chapter
dna 9frotmnencing with Section 700(lof Divism.3ofiba Businessand Professions Cade) SWIMMING POOL ELECTRICVp ATION
or hal he k.cmunpuh,refmmamd the basis forth,alleged exemption.Any violatiaaof CIA LETSF Z Q -SWITCHES-FITURESSection 7031.5 byny aplicant fora variant subjectsthepdond m
not mmethan five hundred dollen(f500). .
Co ❑ I..,,.nro0heproperty,ormyemployeeswithwagesutheirsolecompensmNEW RFSIDENTIAI.ELECTR 5 IT.ion, Q $'TOR TYPE CONSTRUCTION
yg°0 will as the work,and the structure isnotimended proffered forsak(Sec.7040 Business
and Professions Code:The Contractors License Law does not apply to an owner of
propertywholmildsorimpraves thereon,wdwbodoessuch work himself orthrnughhis OC RET.UNITS
ownemployees,provided thatsuch improvementsert not imendedorof&red forsale.If, _ I
however,the building or improvement is sold within one year oreamplefion,theowner- T Y
builder will have the burden of proving that he did rat build or improve for purpose of
sale.).
❑ I,ns ownend,hepropmy,am exelmively nmtreaing with licenxd,.ntmnom to QTY, PLU BI RMIT FEF.. - FLO O APN
ransomer the project(Sec.7044,Business and Professions Cod,The--ax's PERMIT ISSU
License Lnwdce,not apply to unownerafproperty who builds or improve,laicism,add
who contracts forsuch projects withacontmcouLd licensed punuanun the Contacter's ALTER-DRAIN&VENT-WA'
License Law. PEE SUMMARY
❑ I am exempt under Tea- .R&P C 1'or this rcxson BACK FLOW PROTECT.DEVICE OUTSIDE F.ES
'' Y
Owner Dara - RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX Y N
❑ Thereby affirm,hatlhavencmifcem ofconscm,o ulf-in.......certificateof RECF.IPI'q
FIXTURES-PER TRAP
Workers'Compcnsmion lnrurwcernacenifed copy thereof(Sw.3A00,LabCJ which PARK FEE YN
covers all employees under Nis permit GAS.EA.SYSTEM.1 INC.4 OUD. R[CIJI'1'#
Policy# BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PER
❑ Certified copy is hereby furnished.
❑ Cmiticd copy ix flcJ with the city inepeninn divisiart GRRASE/INDUS1'RL WASTE INME-RCEP'nor GRADING ITE
44
CERTIFICATE OF EXf?MPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This actino need too be completed if thepmnit is fronehimareddollers(SIM) SEWER-SANITARY-STORM HA.2001T. IP4ERGY FEE
or less.)
1,arify,hat in the perfonnancc m fila,work far which this panni,is issued,l shall WATER HEATER WNI?NT/EldCTR
not employ any person in any manner so m to become subject to the Worker% PAID
Z Campematina Luwsof CnliPomia. Date WA'I'ERSYSTEMTREATING Data Receipt#
Applicant
OO NOTICE T'O APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
fA became sobject n the Workers Compenswou,rovisions fdo,Luber Cdde, ter must
; forthwith comply with such provisions.,this permit shall be deemed mvaked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the perfomame,of
U the work!..which this permit is issued(Sec.30)7,Civ.C.) TOTAL: ELECTRIC ITE
,.enders Name
U herder's Address QTY.i, MECHANICALPERMIT FEE PLUMBING ITE
1 certify Nat 1 have read this application and state that the above information is '
correct. lame to comply with all cit and count ordinances end site laws bidding to PERMIT ISSUANCE MECHANICAL FRE
g PYwi Y' county g
1-' y building construction,and hereby authorize representatives oflhis city to cnterupnn the
U above.mentioned property far inspection purycs.osALTER OR ADD TOMECH. CONSTRUCTION'TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabiliiies,judgmems,cosis and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
iii'in naa,mace of the granting ofthis panni,.
AIR HANDLING UNIT(OVER 10.003 CFMIIS I
ignition,of Applic muContrinar Dam EXHAUST HOOD(W/DUCT) PAID '
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt is
Will the applasntor future building occupirtiame or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
us define4 by the Cupertino Municipal Gale.Chapter 9.12,and,he Health and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RESID)
1:1 yes, 11 No
Will heapplicamor furore building occupuntuseequiptrmntordevices whichemit
BOILER-COMP CHP OR 1M."BTU) ISSUANCE DATE
�hazordoos mr canoamivants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
Damn?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. OCT
1 have read the hazardous materials requirements under Chapter 6.95 of the g 1
an
ifteuling Health s .at cu Coag genions 85115.25533 and 25534. I ity to nond that California the building does no,elyrt tlyde haves tenant.@otitis and 25534ih1 an eslandt at
occupant of the teats which must be.,at prior .issmmce of a Can of C11 Y U1- `VIa.
Occupancy. - I1 l
owner or authoneed ngem Dat TOTAL: ISSUED BY:
OFFICE