25520 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILTNG-ELEC RI AL PERMTTNO.
APPLICATION/PERMIT PLUMB
BING-MECHANICAL /A 5 '5 L 1"' r/�
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAII
S A 1 rive UNIT LOT# c�- 3
OWNS NA E: F PHONE: CONT OR' N LIC NO: N/C CONTROL#
ARCHHECT/EhIGINF.F:R: LIC NO: ADDRESS: ❑ T
PHONE:
nc .fS J�.J��O/_ QTY E✓EC'fR CP Mff FL'E BUILDING PERMIT INFO
W— 5W BLDG EL CT PLUMB SUCH
PERMIT ISSUA CF: � � ❑
LICENSED CONTRACTOR'S DECLARATION APPLIAN S- (DENTIA OB DESCRIPTION
pyZ Thereby affrmthu lam licensed underprovisionsof Chapt<r9(<ommencing with
WOO Section 7")of Division 3 ofthe Business and Professions Code,and my license is i pqN
Km, fullforce nse Cland effect.
F y hiceme Claes Lic.# UP 2W AMPS
Nth Dttc Conlydedm 1 ` -I(SX)AMPSt
Z OIis7 ARCHITECTS DECLARATION OVER IPOO PS SQ.FT.FLOOR AREA $/3Q.FT.
O Z' I understand my plans shall be used as public records.
P:Li=W SIG L
QyE, Licensed Professional
XOes< OWNER-BUILDER DECLARATION SP IA CUIT/MISC.
a I hereby affirm that I am exempt from the Commerce,License Law for Ne
:Y3a-vFi following reason(Scnion)03 L5,Business and Professions Code:Any city or county TE TER OR POLE(NST.
E]O; which requires a permit to construct,alter,improve,demolish.or repair any structure
}S prior to its issuunce,uLmrequires the applicant!msuch permum filaaslgned statement PO4 DEVICES
'Cp<O that he is licensed pursuant to the provisions of the Commoners License Law(Chapter
dXo ff 9(commencing with Scenion 7")ofDivision 3 m me Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIONS'
m_m orthat be is exempt therefrom and he basis for the alleged exemption.Any violation of �-
I. Z, Section 703 L5 by any applicant for a permit subjects
Nts the applicant 10 a civil penalty of OUTLETS-SWITCHES-FIXTURES O�
—p nmore an five handed dollars($500). NEW RFSIDLNTIAI.ELECTR _SQ.PT.
a m ❑ I,asownerofihepropeny,ormyemployeeswiNwagesutheirsolecompensatioa, STORIES TYPE-CONSTRUCTION
y willdothevv k,and ihesmucWre is nm lmendedoroffered forsule(Sec.91144,Business
and Professions Code:The Contractors License Law does not apply to an owner of
pon,my who builds or improves Hereon,and who does such work himself or through hit
employees.provided that such improvememsarenot intendedoroffered 6rsale.if.
OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yearnfeampletion,theowner. T
builder will have the burden ofpmving that he did not build or improve for purpose of
sole.).
❑ I,asownensfthepropeny,amenclusivelyconp Eingwithlicensedcmtmcmrshs QTY. PLUMBINGPERMIT FEE FLOODZONF. APN
srun the project(See64
74,Basmal
es,and professions Ce:)Tho Contractor's
License Lawdoes not apply to an ownermproperty who builds or improves thereon,and PERM]IISSUANCE
whocomcacuforsuch pmjectswithacontr tos)ileenudpumuammthe Convenor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. B&Y C for Nis Beason BACK FLOW PROTECT.DEVICE OUTSIU FE S
Owner SANITARY Y N
Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherebyalfrninion,have a cenllicareofconsenuo self-irvatmoracerificauof FIXTURES-PER'I'RAP RECFIPT#
Workers'Compensminn Insurance or a certified copy themof(See.3900,Lab C.)which PARK FEE Y_N
polers all employees under this permit
icy# GAS-EA.SYSTIiM-1 INC.4 OUTLETS RECF,IPI'#
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 EA) ^`
❑ Cod iOed copy is hereby with
the city
( PI-ANCHECK FEE
❑ CmifiW copy is filed will Ne city irapection division. GREASHRNDUSTRL WASTE INTERCEPTOR GRADING FEE
C17RI IIICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lithe permit is forme hundred dollars IS TOO) SEWER-SANITARY-STORM EA.200Fll
It's) ENERGY FEE
I certify shat in the peramuncerfthc work far which Nis permit is issued.l shall WATER HEATER W/VENT/ELECIR
not employ any'.io any manner so m to become subjmt to the Workers PAID
zCanpensmion Lawsof Califomu. Dae WATER SYSTEMOREATING
Applicant Dam Receipt#
Q
z 0 NOTICE TO APPLICANT:If,after making this COoficare oftexce ion,you should NEW RESIDENTIAL PLMB. SO.ET'
FLn hesomes.bjcctm the Workers Compensation no,itmosof the Lido,Code,you must ,TOTAL.
ga ; limhwith comply with such provisions or this Permit shall be deemed revoked gELEM]CPLE
Q CONSTRUCTION LENDING AGENCY
Z 1 hereby affirm that there is a construction lending agency for Ne pco mlantt of Ej
V O the work for which Nis permit is issued(Sec.3119],Civ.C.). TOTAL:1<nders Namrc0I" finder's Ade ss QTY. MECHANICAL PERMIT' FEE EU1 certify that I hove rodthis apps' antl sum That the aMwe information i.smrcn. la t comply with all ci a numy orJinances ani sure lawsrclrdnglo PERMIT ISSUANCE ITEbuildings s0 lionand hereby TV z ahuve-m rola pr0pcny for incti n purposes. ALTER OR ADD TO MECH. CTION TAX
lW)a to save,indem 'f d kmp harmles c City of Cupcnino against
liabiliti us which may in way arecmcagainst said City AIR HANDLING UNIT U70 I O,Opid CFM)
in con graining of I.
AIR HANDLING UNIT(OVER W.NR CFM)
Sign mreof Applica Do P.XHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,900 BTU) Date Receiptp
Will the applicant a farm,building core building oupant sor handle hanrdids material
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Heald,and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)9
13 Yes 0 N VENTILATION FAN(SINGLE RESID)
Will lhea licanl or futom building occupant quipmen BOILER-COMP(3HP OR 100,000 BTU) PINSXjC®
Districts ATB
�hamicts mu
air c0nminonac defneJ by the Bay Area Air Quality Management BOILER-COMP(OVER If),"BTU)El Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have tad the Immodous materials requirements under Chapter 6.95 of NSEP 181993
/� y 93
Califomia Health&Safety Code,Sections 255115.25533 and 25534. 1 understand that C//f uI,
iflhe baimmg does mm curemly have a Intel,Nm it is my mspnmibility to notify the V/"Cfy 111 VV
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or amhorieed agent Dae
TOTAL: ISSUED BY:
OFFIC