25241 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONrii�rsolFRICAL PERMIT NO. ^
APPLICATION/PERMIT PLUMBING-MRCHANIFIC L
BUILDING DIVISION r BUILDING PR(1JF.CPIDENTIFICATION
5241
BUILDING ADDRESS: Oxy,, ) - SANI'TARYNO. LICATIOOKSUBMMIITTTAALDATE
2 ✓ 4 d, N Q UNIT# LOT#
h ac SCr
OWN N'Me: ,K PHONE: C R C '3 AME: O� LIC NO: N/C CONTTRRO---L# {{{/
ARCIIITECTC/ENGINEER: LIC NO: -ll��...•wwVV1t OIK, !C%N/7 �� ❑
CONTACT: - PHONE: rad & -
QTY.-d g 4HLECiR.I4s PE MIT x .: <PEH °, ` BUILDING PERMIT INFO"'
1' /� 1 hF#' ti '� nBLDG BLP. PLUM ECf
Ft,k;,.- oe Oryrlk 252- 3 ] PERMIT ISSUANCE
LICENSED CONT CTOR'SDECLARATTON PPLIANCES-RESIDENT W. /� JOB DESCR 'ION
QWz I herebyaffirm that l am licamedunderprovisions of Chapter9m
(comencingwith
ts100 Section7000)of Division 3of the Rosiness and Profeseia�Code,and my license is in pgrygLg
full force and effect O
y<zyl License Cl ^- _ Lia nvor, 1' UP TO 2IXI MPS
d Date Contractor, 'b/ r 20I-m00 AMPS .
Z8y7 ARCHITECTS DECLARATIONOVER 1000 AMPS y SQ.Fr.FLOOR AREA $/SQ.Fr.
O Z_,W I understand my plans shall bh used as public records.
F'.N.F W SIGNS ELECTRICAL
Q� a Licensed Professional OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. I�
cDC O W U 1 hereby affirm that I am exempt from the Contractors License Law for the '� �� I u G �
W B W vi fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METFR OR POLE MST.
Oa which regniresapermit to cnnsvud,elrer,improve,demolish,or repair any swcture POWERDEVICES L-
�NQ tied he
ilicensed pursunttoree tprovis icsofore Contractors
La statement DATE
W p O that he is licensed pursuant m the provisions of tM1e Convacmr's License Law(Chapter
mmxCSWIMMING POOL ELECTRIC
- VALDATIDryfI/�
ly,�y or0stheis1.5 by tyapplimand the Permit
Any ivilpaeallyid UTLETS-SWITCHES-FIXTURES �� O
E ¢ ounin
Section 9031.5 by any appllcantfor apormit suhjeata the appllcanuoeclvll penepy of ✓VVV
net more than Five hundred dollars($500). NEWRESIDENTIALELECTR S .FT.
W ❑ I,asownerof the prnpertyprmyemployeeswith wagesasthei,witecmpensation, Q STORIES TYPECONSTRUC'HON
1 will do thework,undthestrtmture is not inlendeltroffcured ror.sale(Sec.71 ,Business
and Professions Code:The Chmmutors License Law does not apply to an owner of
propertywholumusorimproves thereon,andwhodoessuchwork himselforthroughhis
own mnpleyees,provided thatsuch improvementsavenot intendedoroffered forsale.If, OCC.GROUP , RES.UNITS
however,the buildingor improvement is sold within one yearofcompletlon,theowner- A '
builder will have the burden of proving that he did not build or improve for purpose of
sale.). ff s- og e..F a4'. rtrii" .
❑ I,as ownerofthe property,amexclusrve]y contracting with licensed chalm<tm to Q Y. i 'PI•UMBINd PGRMITr r, ;PEE" FLOOD ZONE APN
consouht the project(Sec]004,Business end Professions Code:)The Contractor's
License Lawdoesnot apply man ownerofFoperty who builds or improves thereoq and PERMIT ISSUANCE _
who contracts for such projects with terminations)licensed pursuant o the Contractor's ALTER (EA) _ ARY
Laurie IMiSUMM
-
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE "ANOUTSIDE FEB
SITARY YN
Owner Ram RECEIPT#
DRAINS-FLOOR,BOOP,AREA,COND.WORKMAN COMPENSATTONDECLARATION SCHOOL TAX Y N
❑ IherebyaHlnnthat lhave acerta comeof or,thioid r-insure,ore certificate of PIXTURF.S-PER TRAP �- RECEIPT#
Wmkere Compensation lnsureynSceoracenified wpY U'a'wf(Sw.3800,Lab C.)whlch PARK PEE YN
covers:Jl y .tlWslgmit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
P pan LGA BUILDING DI VISIO FEES
17-he l'—Phed.
ChmpanY I GAS-LA.SYSTEM-OVER4(GA) PLANCIIECK FEE
Certified copy IS hereby Finished.
edified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthepermit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or ess.)
I certify that in due performance or the work for which this Permit is issued,ISol WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the WorkersPAID
O z CAPpmlpareadion Liens of California. Date WATER SYSTEMIMEATING Date Receipt#
icant
C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RES]DENTTAL PLMIL SQ.Fr. TOTAL:
(•" M become subject to the Workers Compensation provisions of the Labor Code,yon must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING ME
z CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby affirm that there is a consovetion lending agency for the perfonnence of
U O the work for which this penmt is issued(Sec.3(th Civ.C.) Tlop: ELECTRIC IFEB `
LTr .y Landers Name ,,-0 a "'?? ' PLUMBING FP.E
0 F Lenders Address QTYa t$ MECHANICAL PCRMI'fa 'e-a-PP.Exk
U 1 certify that 1 have read this application and state Nat the above mfom soon s #" " " '
correct.I agree m comply with all city and county ordinances said state laws relating w PERMIT ISSUANCE r MECIIANICALFEE
� building construction,and hereby authorize ropresentalives of this city to enter upon the CONSTRUCTTON'fAX
U Z above-mentioned property for inspection purposes. - ALTERORADDTOMECH.
H (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and ex which may in any way accrue against said City AIR HANDLING IMIT(1010,000 CFM)
ons the grantin this pe t.
_7O AIR HANDLING UNIT(OVER I0,000 CPM)
Sigrr,ure of Applies /Contractor /IData EXHAUST HOOD(W/DUCT)
PAID I
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt is
Will the applicant or future building occupant store m handle hazardous materiel HEATING UNIT(OVER 10Q(NIO BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Godo,Section 25532(a)Y VENTILATION FAN(SINGLE REBID)
❑Yes ❑No
Will thea licamorfature buildin BOILER-COMP(3HPOR I00,000BTU)
ISSUANCE DATE
pp goceupant ueeequipmemordevlwswhich emit
azatdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
'`strict? gy
11 yes El No NEW RESIDENTIAL.MI CH. SQ.Ff. P '` ' D
I have read the hazardous materials requirements under Chapter 6.95 of the �•
California lleahh&Safety Code,Sections 25505,25533 and 25534. I understand that U
Him,building does not currently have atemnt,that it is my responsibility to notify the 93
occupant of the requirements which must be mel prior to Issuance of a Certificate of
ys
Occupancy. ( 1
r
Owner mamhhrbedge
ant Date - T 1 ISSUED BY: /'tYli4VU