25146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO R fl.ult7 Z-�LEc:IRI AI. PERMIT NO.
BUILDING C o ERTN APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 1 4 6
BUILDING PROJECT'IDENTIFICATION
OUILO�GAppR1:55: � UNITM LOTH SANITARY NO. APPLIGTIONSUBMITTAI.DATE
OWN . N —JJII PHONE: CTOMSNAMC: LIC NO:
.C.J �l/S% 50/�^J/$ �'1G33 N(c coNreol.w
i s JTELT/ENGINF.ER: LIC NO: ADD 'SS: �Z
y evzq wl-on ❑ J
CONTACT: PHONE. QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�
.a ^Oaf 1 F.ECT PLUMB F.0 I
_` ` (J PERMIT ISSUANCE El
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDF.N'TIAL JOE DIiSCRIPI'ION
O=Z I herebyaffimn that l am licensed underprovisionsof Chaptar9(commencingwip
PJ POO Section]IIW)of Division 3 ofthe Business and Professions Code,and my license is in PANELS �.rYr��,1" ,
F6F--..ZW fu,cera,Classoffwy Lic.w ����� / UPTO2WAMPS ���/ V�J
In 6 Date L� Coroner, 201-1000 AMPS
ARCHITECTS DECLARATION SQ,FT.FLOOR AREA $JSQ.17.
70n`�7- OVER I(IOOAMPS
O Z�❑ I underatand my plans shall be used as public records. ®�
SIGNS ELECTRICAL
Q LicensedProfessional
hyo' OWNER-Bempt frmEC Contractor's
SPECIAL CIRCUIT TSC.
xy060 I hereby affirm that 1 um exempt from the Cocoons Co License Law for the
LL73fa.y following.arson(Section 903L9.Business and Pre,deannsh.,u Any city or county TEMP.METER OR POL
E Og which rcyuires a mit to construct,ul¢r,improve,Jemnlish,err repair any structure LI
N<E to llsnsused pursuant
urua obex pea Lwnlf the Commences
License
walatement POWER DEVICES
YYuu]] pilar w rp pe g^
y1Ca but he is licensed pursovmmpe provisions of the Contnnors License Lew(Chapter SWIMMING POOL ELECTRIC
aFN 9(commencing with Section 3(IDG)of Division 3 ofthe Business and Professions Code) VALUATION
I�Zy onhm h7031.5 by yappnnrnd Ore PermfonhcasegeJ exemption.Any violation of OUTLETS-SWITCHES- 2a r��
Wa.,Section 7031.5 vemydreddontfora,110). subjects the appiicennoacivil perWryof FIXTURES ..7J ` J
$ t mora then five hundred ny,ors ycinp.
KCS n❑ I,msnwnernf lhepmpeny,ormynnployeeswipwuges ee pcirsolerompcnsmloq NEW RESIDIiNTIAL CLECIR _SQ.FT. STORIES 1'YPF.CONSTRUCI'ION
y$_ will dope work,and thestrvcmrcis not intendeloroffcned forsale(Sce.J044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who buildsmimproves mercon,and whodoea such work himselfor through his
onOCC.GROUP HES.UNI'T'S
wemployees.pnrvidWm pauchimprnvemenls meant intendedproffered Tarsale.If,
however,the building or improvement issold withinone yearof completion,the owner,
builder will have the burden of proving that he that not build m improve for purpose of
sale.).
❑ I.mownerofthepmpeny,amexclusivelyconmciingwiplittnsedcan.mom QTY. PLUMBING PERMIT i F13E FLOODZONE APN
construct the project(Sec.]f1W,Business and Professions Code:)The Contractors
Lcenselswdoesnntapplyloanownerofpropertywhohuildsorimproves thereon,and PERMIT ISSUANCE
who ccnincts for such prajwuwith o conuacto s)licensed Panamint mthe Contncmr's ALTERDRAIN&VENT-WATER
License Law. ('CA) FEE SUMMARY
❑ 1 um exengn under Sec. ❑&P C for This reason BACK FLOW PROTECT.DEVICE 19. DCII S
SANITARY YN
Owliy, Date DRAINS-FLOOR,ROOF,AREA.COND. RF.CEIPPN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
�I thereby affirm that i have a cenificate ofconseni to self-insure,or a certificate of blXTURCS-PCR TRAP RECEIN,a
5 4ken'Companntion lm usawcona mrtified copy,pereof(See.3800.Lab C.)which PARK ME Y N
Eves eNMnyeQ)iuMp, ggtit. GAS-EA.SYSTEM-1 INC.4 OU'T'LETS RECEIPTN
'1�'Nll�/,Y� /✓ EmpTNIGDIVISI( THIS
GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby fumishw. ILUd
,tilled copy is filed with the city inspection division. GREASE1rNDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE
(Thisso,darineed not be completed ifthe permit is for one hundred dollars P$100) SEWER-SANITARY-STORM EA.200Ff. I' GYI '
or less.)
I certify that i a the perlbrmance of the work for which this permit is issued.I shall WATIiR HEATER W/VCNT/ELECTR
not employ any person in any manner so m to became subject to the Workers' PAID
Compenntion Lawsof California. Dale WATER SYSTEWIRFATING Date c I
O Z Applicant
Z NOTICE TO APPLICANT:IL after making this Cenilicmeof Exemption,you should NEW RESIDENTIAL PI.MB. SQ.FT. 'TOTAL.:
(q became mbject to the Workers Compensation Provisions of pe Lehr Cade,you most
� ; forthwith comply with such Provisions or this permit shall Is,deemed revoked. BUILDING FEE r�6 ILA 4173D
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihcrebyaff,.chat the. sysnsiontion lendingigenay for the perfamvnce of TOTAL: F,LF.CTRIC FEE f
U O the work for which this permh is issued(Sea 309"1,Civ.CJ
header's Name
hewers Address QTY, -MECHANICAL PERMIT ITE PLUMBINGFEE
0.U 1 certify thin I have read this application and state that the above information is MECHANICAL ME
comen.Itgme to comply with all city and eeunly odmitaces and state lawa acating to PERM IT ISSUANCE
C") building comruction,and hereby authorize representatives ofthis city to enter upon the CONS'IRUCTIONTAX
U Zi above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep hamlleas the City of Cupenino against
liabilities' dgmm c and expenses which may in any wayecrmeagelmt said City AIR HANDLING UNIT(TO 10.00)CFM)
in co qua ft g tingof thispermit, PIR HANDLING UNIT(OVER IO,IXID(FM)
7J�3
Si m f ppli tlContncmr Date EXHAUST HOOD(WIDUCG PAID
HAZARDOUS MATERIALS DISCLOSURE
RENTING UNIT(TO 100,000 BTU) Date Rccdplw
Will the applicant or Tram building' Code,
stare m handle locations material
redefined by the Cupertino MunicipulCwe,C
hapmr9.12.and[be Health and Safety HEATING ON[TROVES 100,000 BTU) t TPIAr
Code,$colon 23512(e)P VF.NTHATION PAN(SINGLE RHSID)
❑Y. ❑No V
ISSUANCE.DATE
Will the epplicanmrl'uwrcbuildingocnt cupauseequipmem nrdevices whichemit
BOILER-COMP(311P OR IOO,OW BTU)
M1
.as air conlnmmarmi m defined by the Bay Area Air Quality Management
1ru�fc4 BOILER-COMP(OVER 100,000 BTU) x1 /
M
❑Yea ❑No NEW REMDENTIAL ECH. %Ff. 9G0a
A'V
1 have read the hicum see materials rcgmirent under Chapter 6.95 of the Ya('
California I leehit h Safety Cuda,Sections 25505,25533 and 25534. 1 understand that y(��
if the building docs not currently hove a mnent,pet it is my rcsponaibiliry m notify the F'G`Lti
occupant of pe requirements which must be met prior m issuance of a Certificate of
Occupancy.
Owner or authorized ager Date ISSUED BY:
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