25374 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .DING-e PERMIT NO.
APPLICATION/PERMIT PLUMBING10FROJFCTID IDENTIFICATION
25374 C 3 7 A
BUILDING DIVISION HUIIAING PNOJECf IIIF:NTIFICATI(IN GJ I /•t
564I.DING ADDRESS: SANITARY NO. APPLICA'T'ION SUHMITT'ALDATE
I O R 11 S ANJTA T'ER ESA P 12-. C UNITp Cl P 2 71(00, CiI.Ot S v /� t,
1 Ttl
O NERS NAME: �s. 1 PHONE(w — CONTRACTOR'S NAME: LIC NO:
I - TS QnJ W 2ST—yokstromeq3Q1IO N/C COM'ROLs
RCHTIECOENGINEER: LICNO: ADDRESS: Ca 0 ❑
CONTACT: PHONE: BUILDING PGRMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELIiCI' P UMB MGCIi
PERMIT ISSUANCE El
El LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RRgIDRN UAL JOB DESCRIPTION
p(yz Iherchyaffrm thalvm licensedunderprvvisiomnfChager9(commencing with
EE fall irrovi def Pro
Division the Business and Professions Code,and my license is PANELS
G y� License Class LicY I UP TO 200 AMPS
tFit6y Dale ConWclar 201.1"AMPS
7 FONZJ ARCHITECT'S DECLARATION OVER IOOOAMPS SQ.FI'.FLOOR AREA $/SQ.F.
O Z,.-p 1 undersand my plats shill he uuJ i s public records.
F y F; SIGNS ELECTRICAL.
g � Licensed Professional
all
DECLARATION SPECIAL CIRCUIT/MISC.
KOP.0 I hereby affirm that I an exempt from the Contractor's License Law for the
tzl3ay following rcason.(Senion TOJL3,Business and Professions Cale:Any city or county TEMP.Mm. iRORPOLF.INST. n f,
C
such requires a permit¢i construct,abler.improve,demolish,or repair any suucmre b
a Ym poor to its issuance,als.requires the applicant fimmch permit to Rleasigned stotemem POWERBYIq I
LLLLII <0m mw he is licensed Pnrsavm m the previsions oflhe Common,......i......w(Chapmr SWIMMI CP. E
aae61 9(commencing with Section of Division 3 offle Business and Processions Code) �, VALUATION
or he is exempt therefrom and the basis for the alleged exemption.Any Violation or OIITLEf I -FlXTURij
Zi- Section 9f131.5 by any applicam for a permit subjects the applicant to a civil penally of
TPIFAY".re than five hundreddoll..($5W). NEW RFSIDP rr�g�y�n:;CIR.anwnerofth 'ITS" STORIES TYPECONSTRUCTION
nrk,vnd lhcmiuclae is nal imeadvilmuffered for Cut,(Sce.7044,Businessssions Cade:Tho Contractors License Law does nm apply to en owner of
whobuilds or improves lhereomand whodoes such work himselfor throughhis
1 deo that such im t t t ddoraffeted forsale.If, OCC.GROUT' RES.UNITS
ever.oetimilrovi pmvemensmeno in ane
however,the building or impmvemem is hold a oldnoneyearof completion,me ownei-
huiWerwillhuvclhebunlCnOf that he did not build or impress for f TOTAL:
Proving P purpoua
ale.). QTY. PLUMBING PERMIT FEE FLOODZONE - APN
❑ I,nsawnerufthe ProPcrty,am exclunivelycantmning with licensed contractors
construct the project(Sac.9044,Business and Professions Crvlep The Contractor's
License lnwdosnotapplyloanownerofpmpenywhobuildsorimpmvu Nemon,and PERMITISSUANCE
whocomractsforsuch projects with neolnractor(s)licensed purnmento the Contractors PETER-DRAIN&VENT�WATER(EA)
License Lvw. PGE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FRES
SANITARY YN
Owner Dam RECEIPI'k
DRAINS-MOOR,ROOF.AREA.COND.
WORKMAN COMPI7NSAT10N DECLARATION SCHOOL FAX YN
❑ Ihercby uffrm ihullhave ucenifcae of cnnsenno sal&insure.ora cenifwte of RICEIPrp
FIXTURESPER TRAP
Wmkers'Compensaion liisurance ora certified copyrorrof(Sa.3800,Lab CJ which PARK PEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RIiCEIPT p
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIPECK FEE
❑ Counted copy is hereby furnished.
❑ Combed COPY is filed with the City inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section account be completed iRhe permit is Salinas hundred doll.,.($too) SEWER-SANITARY-STORM EA,20017. ENERGY FEE
or I as.)
I cerif din in the poof.....f the work far which this permit is issued,i shell WATER HIATF.R}VNFM/ELECTR
not employ any person in any manner so as to become suhjwt to the Workers' PAID
Comperoationlawsof Celifomiv. Date WATER SYSTEMG`REATING Date RvCcgea
z Applicant
z C) NOTICE TO APPLICANT:If after making this Certificate of Exemption,you should NEW RES[DHNTIAL PLMR. SQ.f7. TOTAL:
t- Vl become subject to the Workers Compensation provisions of the Labor Cade.you must
�i forthwith comply with such provisions Or this Permit shot[be doomed revoked. BUILDING FEE
L1a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby at than that there Is a construction lending agency for the pernmarne,of
V O the work for which this permit is issued(Sce.3099,Civ.CJ ELF.CI'RIC PEE
r
Imnder's Name
OF Lender's Address QTY. ` MECHANICALPHRMIT FEE PLUMBING FEE
r W1 ceairy that 1 have read this application end state That the move infmveaiun is
correMECHANICAL FEE
ct. I agree to comply with all city and county Ordinances and state laws relmingm PERMIT ISSUANCE
f—' V) building construction,and hereby authonze representatives ofthis city menno.ponthe CONSTRUCTION TAX
V vove-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We).gree to save,indemnify and keep harmles.the City of Copertioc against
[imbilhicajudgments.eostsand expenses which mayin any way accrveagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
'a ocursaillsoccoof@e grand. of Nis penton.
AIR HANDLING UNIT(OVER 10,000 CPM)
S' num APPlicanVCutinacmr Date L%HAUST HOOD(W/DUCq
PAID
HA]ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) ]).to Recloth#
Willmo applicalo,fawn building occupum store or handle hua.Nou,material ryFiAT'ING UNIT(OVER 100,000 pill) 'roTA1.:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
❑Yes es 11 No Code,Section x)7 VENTILATION FAN(SINGLE RESID)
Will the upplicanl nr lumrcM1uildingoccupam use cquipmentnrdevices whichemil
BOILER-COMP PHP OR 100.(p0 BTU) ISSUANCE DATE
harardousair Contaminants ss defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? �pq
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.ITL r All)
I have read the hazardousA
materials requirements under Chapter 6.95 of the
California Hezllh&Safely Code,Sections 255115,25533 and 23534.I understand list ���
If the building does not currently have a tenant,that it is my responsibility to notify the
moment of the requirements which most ho mel prior m issu...o of a CeniOcme of 93
Occupancy. N7
Owner nr authorized agent Date TOTAL: ISSUED BY:
OFFICE