28195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - BUILD J (:-F,LEC'IRICA L PERM)fNO.
APPLICATION/PERMIT _ PLUMBIN;-MECHANICAL. _ O eI C
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION o1 J
BUILDING ADDRESS: � s� SANITARY No. APPLICATION$GBMpITAL DATELo �II a* LD'1'p
OW ERS NAME;: HONE: CONTjACTOR'S NAA E: LIC NO: CJ
S14 ��►l. aI N/C CONTROL#
�RCHI'IECI'/ENGINEER: LIC NO: ADDRESS: G gV/i ❑ .
CONTACT: PHONE - BUILDING PERMIT INFO
t �z_/G D "Y' hLECI'RIC PERMIT fTE
`T _! BLDG PLUMB M
1'HRMIT ISSUANCE
LICENSED CONdRACTOR'SDF.CLARAHON APPLIANCES-RESIDENTIAL JOB DLSCRIFI'ION
WOO I hereby afxmnhat l am licensed underpmvisions of Chnp¢r9(commencing with
X00 Sectiun7001)mf OivisinnJ of tM1m Buxlneesand Profesyluns Cute,trod my license is in PANP.1,5
,W46
fail force and effect.
NLicense Clnsv Lic.p Of'TO 200 AMPS
a Dam Contractor 201-1100 AMPS
FNm ARCHITECTS DECLARATION SQ.FL FLOOR AREA E/SQ.IT.
zzr3G I understand my plans shall be used as public records. .OVER IOW AMPS
OO
n
SIGNS ELECTRICAL
Q` .,] Licensed Professional
PJ'y�P'Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
KOyF I hereby afEnn thm.l can exempt from the Convenor's License Law lin the
W 30ot following reason.(Section?031.5,Business and Professions Cale:Any city or county TEMP.METER OR POLE INS1'.
NasI which requires a permit to constrecl,after,improve,demolish,or repair any.vucmm
E YE mormacissuance,also tequitesthe applicant torsuch permirto file.signedsmtemem POWER DEVICES
00 Ihul he is licensed pursuanno the pnwinnic of the Contractors License
Luw(Chapter
o.ao� I(commencing with Section 7000)mfDivision 3ofdf Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
m0na he is exomgn themn..nund the busis for the alleged exemption.Any vlol'darn I OUTLhI'S-SWITCHES-PIX'fURL'S
1—Za Section 7031.5 by anymplicant fore permit subjec¢theapplicannn.1ty.
o.civil pef
oto than five hundred Jollurs(§SW).
pmpmy,mmyemploymswith wages ustheirmlecompcnaa0on, NIiW RI3SIDI3NT'IALELCCTR _SQ.IT.
�_O I,asnwncmObe S'I'ORICS 'I'VPE CONSTRUCTION
a3 wills work,and the structure is not intended oraffered hostile(See70144.Business -
and Professions Code:The Comrvnnrs License Law does not apply of an owner rat
pmprny whobuildsorintproveethemon,andwhodoessuch work himselforthnmgh his
ownemployces,provided that such improvements are not intended oroffered lbrmle.If. OCCGROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden mf proving that he did not build or improve for purpose of
saie.).
❑ I,as owner nfihe property,am exclusivelycnntrecting with licensed connnO...,, QTY' PLUMBING PERMIT Pli;
1111
Licmmm Law. : , TODD ZONE AIN
mnswct the project(Sec.7040 Rusimas and Professions Coda)The Commences PERMIT ISSUANCE
License Law doer not apply man owner oI'property who builds"odmproves thereon,and
whocomrvcmfor such projmts witltvmm
cocm(a)IicensW pursuant otm
he Cmmcmh ALTER FEF,SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason RACK IlOW PROTECT.DEVICE O S OL FI:I 4
NTUARY Y N
Owner Dme RECHIF1'#
DRAINS-FLOOR,ROOF.AREA,COND,WORKMAN COMPENSATION DECLARATIONS H L YN
❑ thercbyaffnOon In M1oveceorsconifie consemereof(insure,o,acentl)which @XIlIRES-PER TRAP RECF,II'l'#
Wnrkers'Compemation Insurance nracenified copy threof(Sec.JSW,Lab CJ which PARK PEE YN
covers all employee's under this permit. GAS-IA.SYSTEM-1 INC.4 OUTLETS- RECEIPT'M
Policy N BUILDING DIVISION FEES
Company - GAS-ISA.SYSI'HM-OVER 4(FA) PLANCHECK FEI3
❑ Cenifiedeopyishemby0vnished.
❑ Cenilied copy is tiled with the city inspection Aivision, GREASE/INDUS'I'RL WAST 17 INTERCEPTOR GRADING FIRE
CERTIFICAI'ROF EXEMPTION FROM WORKERS' GREASETRAP SOILS FTE
COMPENSATION INSURANCE
(Thissectmn need not he completed ifthe permit is formic,hundred dollars(SIM) SEWER-SANITARY-STORM EA.200171. 13NERGY ME
or less.)
I cert by that in the performance ofmc work for which this permit is issued,Ishall WATER HEATER WAIENTp3LECB
not employ any person in any manner so as to hcome subject to the Workers' PAID
Cmm,sommion Laws of California. Date WATER SYSTEM/IREATING Date Receipt#
Oz Applicant
zq NOT ICE TO APPLICANT:If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMB.—SQ IT. TOTAL:
s" T/) becomti
e subject the Workerf N
's Compensation provisions at Labor Code,you must
s`2a 1 fin s,ith comply with such provisions or this pemtit shall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SHISMIC PFA
'J z (hereby affirm(lint is v construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3W7,Civ.C.) TOTAL: HLEC1'RIC THIS
Lenders Name
O U Lenders Address QTY. M17CIIANICAL PERMIT FEE PLUMBING FE
I cenify Thal 1 have react this applienim and state lhm the rlwve information is
concert.lagreemmmmplywithalldlyanicmanty ordinances and state law,relating to PERMIT ISSUANCE MEC I IANICAL FEE
but thing construction,and hereby authorize representatives of city to enter upon the
U z above-mentioned properly for imtemion purposes. ALTER OR A DD'TO M HCH. CONSIRUCTIONTAX
(We)a to use,indemnify a keep harmless the City CLpenino against
liabilities ' menes,cons exp which iaaaywaya ere agains. id City HANDLING UNIT(TO 10,WO CFM?
in con eoftli r mem permi
AIR HANDLING UNIT(OVER 10,1100 CPM)
TO"SI old nl Ap sunt/Contraao Dam 13XHAUST HOOD(W/DUC'19 LI PAID
HAZARDOUS MAI HRIALS DISCLOSURE I HEATING UNIT(TO IW,OW RTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous maternal
as deMeO by the Cupertino Municipal Cade,Chupmr 9.12,and Ihc,health and Safe,, HEATING UMT(OVER 100,000 BULB TOTAL:
CaR,5 i tion 25532(e)T VENTILATION FAN(SINGLE RFSID)
❑Y5 ❑No
WIII Iheapplleamorlwure hulldingswcupum useuryipment ordeviceswhdcherrit
POILIiR-COMP(JHPOR IW,000 BTU) I S'A EDATB
hazardous it cnnmminenm as defined by the Bay Ares Air Quality Management BOILER-COMP(QYER IW,(00 BTU) JUN /]O 1995
❑twin? (� til l�JY
L❑Yes ❑No NEW RESIDlE IALMECH. SQ.Ff.
read the hazardous materials requirements under Chapter 6.95 mf the CITY Ur UUr&HIINU
eain&Safety Code,Sections 25505,25533 cad25534. 1 undersmndthm
g ones not currently have a moral,that it is my responsibility to amity the the requirements which must be met prior m issuance ofa Cerlificam of
llmdzed agent Date L: ISSUED BY:
OFFICE