25027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
U11.6TN1`,TION/PERMIT 'F.LRCTIi PERMIT N(3. O
CITY OF CUPERTINO APPLICAPLUMBING-MSC IIAN ICAI. 1
BUILDING DIVIRION BUILDING PROJECT'IDENTIFICATION
27
BUILDING ADD/R�FSS: G ��--// I' //`` SANITARY NO. APPLICATIONSUUa/BMMfITALDATE
Ire-7o /�• `9fg4ti/a 6 � UNIT# LOT#
OWNERS NAME: PHONC: ONTRACTOR'S NAME: LIC NO: N/C CON TR l.#
El
sT g _ 6fK
RGI I I'I'PC'UENGINFER: LIC NO: ADDRESS:
,a4
-OWACT: PHONE.: BUILDING PERMIT INFO
t - QTY ELECTRIC PERMIT FEE
III ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWZ Ihereby affinnthet l mo licensed underpowdons of Chapmr9(commenciagwith n1. \V
e 00 Section 7000)af Division Sof the Busirstrimd professions Code,md my license is in PANELS �
Y1 ' \v
tFy-� fill force and effect. UP TO 200 AMPS FV
QZZ Liaise Class CO.p
y<y Uwe EDf IDI-1000AMPS
ARCHITECTSF.CTS
ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/S .FT.
Z FONZ OVER 1000 AMPS
CZ-0 1 understand my plans ahvll be used as public records. !t`�
SIGNS ELECTRICAL 13�/
Q , Licensed Professional
nC'rB Q OWNCR-BUILDER DECLARATION SPECIALCIRCUTDMISC.
XO a V 1 hereby affirm that I mom exempt from the Contractors License Low for the
W 3"-y following reason.(Section 7031.5,Business and Professions Code:Any city or dairy TEMP.METER OR POLE MST, a ,
F LLJ which requires a permit to construct,alter,improve,demolish,or repair my swctute
primmoi'sissuance,alsmrequire,due.,licunt for such permit to file.signed statement POWER DEVICES
W 60 that he is licensed pursuant the provisions of the Contractors License Law(Chapter VALUATION w�
aao�' 9(annmencing with Section JOWlof Division 3 of,h.Business and Professions Code) SWIMMING POOL ELECTRIC + �J
� 4 or lhnt he is exempt therefrom unJ the basis fonbe alleged exemption.Any violation of QUTLBfS-S' TCHE�FIXT{1�tES� _ 1 ^ C 1
F Y Scctinn 703 LS by my applicvm fur u permit subjects the vpplicem to a civil permhy of (, O
0 ant more than five hundred dollars(E5W). NEW REBID AL ELECIR
C ❑ I.asownemftheprop ay,ormyempleyeeswithwagesastheirsolecomp mafim. STOR S 'TYPE CONSTRUCTION
i3— willdo the work,and the structure isnot immrdedorofferedforsele(Sec.J044,Business I`Jy
FER
and Professions Cade:The ComO.ctor s License Law does not apply to an owner of
propenywhmbuildsmarproveathmam,and whodoesauch work hirmelfmthrough Ns OCC.GROUP RFS.UNITS
ton employees,provided that such improvements are not intendedcanffered for awe.If,
however,the building orimprovemenl is sold within one year ofcompletion,moment, 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
We.). ------`
❑ 1,as owner afore properly,um exclusivelycontracting with licensed contractors w QTY. , PLUMBING PERMIT FEE III ZONE APN
antrum the project(Sec.7044,Business and Professions CWc:)The Contr.dor's
License Lawdoes not apply to un owderofpropcnywhobuildsor improvesthemon.and PERMIT ISSUANCE
whacom acts forsuch projects with a contrector(s)licensed purauam to thecmdrecmra
License law. AUDER-DRAIN&VENT-WATER(HA) FEF.SUMMARY
❑ I man exempt under Sec. ,B&P C far this reason BACK FLOW PRt]TECT.DEVICE OT. DI . .
SANITARY Y N
Owner Data RF.CF.II'1'#
DRAINS-FLUOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑' Ihereby affirm that l have a certificate cremation to self-insure,or a certificate of FIXI'URF.S-PER TRAP RECEIPI'p
�Wotken'Compensation lnauom.mu certified copy thereof(Sec.3800,Lab CJ which PARK PEE Y_N
aeesttt�
pkt; leaner&aril employee's undenM1is pcmtit. GAS-IIA.SYSTEM-I INC 4 OUTLETS BUILDING DI ISION IBES
aGs�-aPnlicy#
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK .E
❑ Cenifiedcr,,n1erebyfumished.
❑ Cerifmdemy is Bled with the city impectiondivision GRFASF./INDUSTRL WASTE INTERCEPTOR GRADING r
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASE'IRAP SOILS FFto
COMPENSATION INSURANCE
(This anxim.rcednm he completed ifthe permit is forme,hundred do][..($100) SEWER-SANITARY-STORM P.A.200111'. ENERGI 'ter
mrleas-)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENDTLECTft
not employ any person in any manner so as to biome subject to the Wurken' P )
Compensation Laws of California. Dom WATER SYSTENEDEATING Dat Receipt#
O Z Applicantn
Z 0 NOTICE'TOAPPLICANT:If,aftermaking this Certificate ofExemption,you should NEW RESIDENTIALPLMB. SQ.IT. 'TOTAL:3 2-7,7'Z
F' Ln become subject to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit&ball be deemed revoked. BUILDING FEF. ��
7
(� CONSTRUCTION LENDING AGENCY SEIS MIC FEE
D
1 hereby affirm that is a Construction lending agency for the performance of 1100
,Z TOTAL: ELECTRIC FEE
I, 0 the work for which this Permit ie issued(Sa.3(19],Civ.CJ
I<dera Name PLUMBING PER
F ntenders Address QTY.:: MECHANICAL PERMIT FEF.
L1 1 ramify that I have reed this application and state that the have of s mident is ' MECHANICAL FF.P.
tLT1 correct.l agree to comply with all city and county ordinances and state laws relating to PC RMT ISSUANCE
F-' h building construction,rand hereby awhon,ut representatives of this city to enter upon the CONSTRUCTION TA
V Z shove-anodoned properly for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep hmmlesa the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO IO,000 CFM)
in consequence of the granting of this permit.
# AIR HANDLING UNIT(OVER 10.0013 CPM)
o icate PAID Applan/ mmdoEXHAUSTHOOD
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,O0s)RTU) Date Receipt#
Will the applicant or fultim building Occupant store m handle hazardous material I{EATING UNIT(OV It 100,000 BTU) 'I OTAL: 3
ns deli ned by the Cupertino Mmmicipal Code,Chapter 9.12,and the I lealth and Safety
Cole,Section 25532(r)? VEMfItAT1ON PAN(SING REBID)
Cl Yes l�No
ISSU TE
Will the applicator future building occupantuaeequipmentordevices whichemit BOILER-COMP(3HP OR 100,000 BTU) A
haaaNta
mm air conminants is derided by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r gg�5, A
'
'District? (((...,,,...
Y ❑Yes pg,No NEW RESIDENTIAL MECH, SQ.FT.
I have ad wou
the hads materials requitemems under Chapter 6.95 of the A41)D 29 1993
m
iV—
Culifomiallealth&Safety Gale,Sections25505,25533and25534. 1understandthm City ur.if the building does not currently have a tenant.than it is my responsibility to notify the U-ur
occupant of the requirements which must he met pmirn to is uanm of.CeniBeam of
wknernL�f J 1 m
J(�Qb� Al
r authnriz ,gem D.y TOTAL: ISSUED BY: