25703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IJILD;ry x.ELYMICA. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL C O
BUILDING DIVISION BUILDING PROJECT IDEN'FF'H:UnUN � J
BUILDING ADDRESS: �A SANITARY NO. APPLICATION SUBMI'IT A,DAIM
1 r S V/ L ALUNIT# LOT 2
O FRS NAME: {{P�HONE: CONTRACTOR'S NAME: LIC NO:
\ J
7/)CDO 02CJK— I'CRN� LS 'f ( 9 WC CONTROL#
ARCH11'17CUENGINEER: LIC NO: -W,44,1
D RESS: of
4 IFiCQmc l t DlSLA FiQkM�l
CONTACT: PHONE: i `
QTY. iiT ,iLe 8 r 8LCCI'RIC PER MIT FEE ? BUI"LDINGPERMn-INFO
t'4 k'S dr x.E!' - - LCf PS M i
PERMIT ISSUANCE. �'� Lr4�(a
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz I hereby affirm than l am licensedunder provisions of Chepter9(commencing with 8DESCRIPTION
000 Section 7"1 of Division 3 of the Business and Professions Code,and my license is in PANELS 1
etV� full force endo(( r. -5'41X12 UPT0200AMP5 V Trr
Q^ W Li e l s Lic.If 1 L _
N e s Conne 201-1000 AMPS �"
Fy2K, ARC]I ITF.CTS DECLARATION OVER 1000 AMPS OORrI�IRFS�� � - -� $)SQ.I .
z O mp I understand my plans shell be used as public records. 1 p 9`■
O Z t W SIGNS ELECTRICAL '�l
ee
Qx=j Licensed Professional
aet Wv OWNER-Bcmm from the
SPECIAL CBTCUIT/MISC. . f la I E '
3Oa 1 nerchy afflict that 1 um enempt from the Contras C'e License Law for the \ L
OIa following a.(Section construct,
Bu sines and improve,
danorts Code: city structure TEMP.METER OR POLP.INST.
FpFp..♦.]'wJ prior
requires a permit reconstruct,alter,improve,demolish,or repair any swemm a•• ` _��+
Mi`c� prior to its issuance also requires the applicant for such permit to Rleesignd statement POWER DEVICES
yy"�-j a QO that he is licensed pursuant the provision of the Connector's License L a (CIT
d Oz 9(rommcncin th Section 7lKKBofDivision3afthe Business and Professiaw Code SWIMMING POOL ELECTRIC ��
ors, (commencing ) ^ VALUATION�n_r�
W_ro or Nethe isexempuhercffact and thebasisrm the alleged exemption,Myviolation of Q OUTLETSSWITCHESFIXTURES 1 /A DDD g"v
Section 70315applicant - -
by any applicant for a permit suhlcets the applican
oa civil penalty of Lh!
t mum Than Ove hmdreJ Mllnra($500). NEW RESIDENTIAL CLECIR _SQ.PT.
n❑ LnuwneroHhepmpeny,ormycmtended roo wagnavlc(Salecompemeness STORIti TYPIiCONSTRUCTION
a 3� will do ams Corundthe he Commences
intended Lrtwrdo s not apply 10 44,Business
and Professions Cotle:The ves trnnor s License law such
or apply lf an owner of
propertywhobultd..idea rovevhereon,andwnodoessuchwork mill fonhrough his
cmployces,provitld!text]such improvememsure notimendcJuroffereA Tarsale.If, OCC GROUP RES.UNITS
however,the building orimprcvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burden or proving that he did not build or Improve for purpose of
sale.).
❑ 1,mownerofrhe Mopeny,mnexcluslvelycon0 cdingwithlicensd nwctorsre QTY:4 a PLUMBING PERMIT IEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Profusions Code)The C' 'e'
I.icensel.awdoesnotapplytoanownerofpropenywhobuildsorimprovesthereogand PERMITISSUANCE
whorodant l'or such projects with aconaactm(s)licensedpursumuotne Contractors ALTP,R-DRAIN&VENT-WATER TA
License Taw. ILA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis ma n BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dale
DRAINS-FLOOR,ROOp,ARFA,CD, RECEIPT'#
WORKMAN COMPENSATIONDECfARAT]ON SCHOOL.TAX Y N
❑ Ihercby affrm!lint]havcuccrtifcme ofconsent mself-inxure,oracertificate of RECEIIT#
FM ORES-
PF.R TRAP
Wohm'Compensatinn Insurance oracerti0d copy]hereof(Sec.3B00,LabCJ wM1ich PARK FEE YN_
covers all employee's under this Permit. GAS-CA.SYSTEM-I INC.4 OUTLETS RRC VIPT#
Policy It BUILDING DIftHON RFS
Company
Cl Certified copy is hereby famished. GAS-EA.SYSTEM.OVCR 4(EA) PLANCHECK FEE
❑ Caddied copy is fled with the city inspection division. GREASE/INDUSTU.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASF.TRAP SOILS FEE
COMPENSATION INSURANCE
(This smtiannewi net be completed ifNepermit is foram hundred dollars(SIM) SEWER-SANITARY-STORM G.2001T. ENERGY FTF
or less.)
I certify That in Ne performance ofthe work for which this permit is issued,L shall WATER HEATER W/VENT/ELECPR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof California. Date WATER SYSTF.MTREATING Raeipt#
O z Applicant
z 0 NOTICF.TO APPLICANT:If.aftermakingthis Certificate of Exemption,you Them; NEW RESIDENTIAL PLMfL SQ.FT. TOTAL:
become subject to the Werkees Compensatina Provisions of the lal+or Code,you must
forthwith comply with such previsions or this permit shall be deemed revoked. BU FEE _#
ON
LTI [] CONSTRUCTION LENDING AGENCY EI IC PEE O
z I hereby affirm That here is a construction lending agency for Ne Performance of -
U O the work for which this permit is issued(Sec.3097,Civ.C.) IT ELECTRIC FEE
Lenders Name p j
0 U Landers Address QTY.•'"Y,t' � MECHANICAL PERMIT' FEE, PLUMBING FEE �.�
O 1 eco fy Nal 1 have read Ili s application r nd state that the above inmrnion a k
comet. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MliCHANLCAL FEE
building construction,and hereby authorize representatives ofthiscity insider upon the CONSTRUCTION TAX
U ,z above-memiond property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmlexs The City of Cupen]no against
Iiabilitic,,id1gmena,cmNimd expenses which may inany way norm,agim,"Tid City AIR HANDLING UNIT(TO 10,000 CPM)
saryc c erring aphis permit.
t t-v 93 AIR HANDLING UNIT(OVER 10,0011 CIN)
Si ren p mdracmr Date EXHAUST HOOD(WIDUCT)
PND
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date RasiptIf
Will the applicant or(marc building occupam wore or ha.Ae hazardous material
To defined by Out Cupertino Municipal Code,Clntpter 9.12,and Oto Health and Safety HEATING UNIT(OVER IM."BTU) OTAL:
Code,Section x)7
11 Yes
❑No
VENf1IATTON FAN(SINGLE RESID)
Yes
Will theupplicaut orfwumbuildingxcupunT useequipmem ordevices which emit BOILER-COMP OHP OR 100,000 BTU) ISSUANCE DATE
• homok a air confidential,as defined by the Buy A.Air Qmlily Management BOILER.COMP(OVER 100.000 BTU)
District? � � � D
❑Yes ❑No NE dLDENTIAL MECH. SQ.FT.
L have read the hazallous materials acquirements under Chapter 6.95 of the jN0V e
California Health&Safety Code.Sections 25505,25533 and 25534. 1 undcommd that
if the huilAing Jres not cumen0y nave n tenant.Nat it is ter rtsspnnRunty to notify the
ecupant nl'Ore rcyuiremcna which must Is,are,prior to main.or.Cedifiaam of
-ter
u ` TIIIIYV
0wnerma
Oor uthorised agent Date ISSUED BY'
OFFICE