25606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF,CUPERTINO B IllyroNli-11L.L lRl AL PERMIT NO.
APPLICATION/PERMIT PLGMIII,NG-MECHANICACIL. /� r /A O/�
BUILDING DIVISION BUILDING PROJE 'IDENTIFICPTL
ION 5 VM I6
BUILDING ADDRESVO O GC� SANITARY NO. APPLICATION
SI
SUUBMSTTAL DATE
ONO# L01
OWNERS NAME PII NE: CONTRACTOR'S NAME: LICNO:
LL/9�E
!;;?V
7g_3
NIC CON IROLp
RCHITE(TURNGINEER: LIC NO: ADDRESS:
'ONTACf: PHONE: - QTY, ELFCTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT [LOMB MECH
PERMIT ISSUANCE ❑ 0 I El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIVI[ON
pyZ I hereby affirn that l am licensed underprovisions of CTaptei9(commencing with
IA00_ Section 700l Division 3ofthc Business and Professions Code.and my limnseis in PANELS /�
1,y-WLFFLss full forte and eIT L /v�.1�i'
UA Limeae Class UPT02MAMPS •�Y V�—
Q � Date ssio as Puhlic rcpnrAs_ 20f-I"AAMPS
hSQ.FT.FLOOR AREA
II
ESQ.17.ARCHITECTS DECLARATION OVER 1000 AMPS
SIGNS
ICAL
J tYhQulC)Z—C �y � 3Chmensed1roe_ �uIW ¢ OWNER-BUILDER DDECWRATION SPECIAL CRLETiMISC.
VQ G_l Imo„ C ! III I T\l
OaU 1 hereby affirm that 1 not exempt from the Contractors License Law for the �I � F
W3aya
billowing was .(Section 7031.5.Business mtd Profession Code:Anycitymcuumy tHMP.METER OR POLE.INST. I �j1 Ill(
gS0J which requires a permit to construct,alter,improve,demolish,or repair any structure
m its issuance,also the applicant forsuch no file a signedstatement I'OWI7R DEVICES
prior quires pp Permit
WOp ,hat he is licenseA pureuum to the provisions of the Contractors License Low(Chapter
,1 0�' 0(commencing with Sedinn9000)of Divisinn3nf the Business and Prol'essinm Gtde) ji
SWIMMING POOL P.LP.CTRIC pA VAhUA'i'ION
mon or(list he is exempttherefrem and the basis for the alleged exemption.Any violalinn of OU'I'I ITS-SWITCHIiS-PI%TURL•S
�K� Section 7031.5 bymty applicant for a permil subjectethenpplicant too civil penaltyof
CFQ not mom than five hundred dollars(S500).
S ❑ I,asownnoftbe m d ,orm em to eeswi(h wa esastheirsolecom tion, NP.W RISIDESTUALELECIR _SQ.IT. STORIES TYPECONSTRUCTION
W—m P Pe Y Y_ P Y 8 pons
a3— will do the workand the structure{snotimendedornReed forsale(Sm.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
propertywhobuildsor improves thereon,andwhoduessuchwork himeelfor through his
own employees,providcd that
ntoomsuch improvomwithin mount eimendWororfernlforowner-
DEC.GROUP RES.UNITS
huilder ,the
ave the burden of pmmngthis aldwi0dnot build ofimproveiourthe
rpose of - ,TOTAL:
builder will have the burden of proving that he dIA not build or improve far purpose of
❑ Lasownerofthepmperty,amexdusivelyconl+using witnlicerlsedcnnwcrotsto QTY. PLUMBING PERMIT PGE FLOOD ZONE: APN
construct the pmjmi(See.2014,Business and Professions Crude:)The Contractors
License Law does not apply manownerofpmpsrty,who builds or improves thereon.and PERM13'ISSUANCE
who cemarmus for such projects with a comracmKs)licensed pursuant o the Contractor's
Liana,Law. AI3ER-DRAIN&VENT-WATER(EA) FETE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for,hie reason SACK PLOW PROTECT.DEVICE. UT. DL 1 ES
SANITARY Y
Owner Date CONE
AREA,, . RECIiI FTp
WORKMAN COMPENSATION DECLARATIONDRAINS-FLOOR, SCHOOL TAX YN
❑Workers'
arrm,tn instavea ace"ifir mpy,h,ofE;ruure,ar Lab
which
RECI?IITp
FI%'TURES-PER TRAP
Wmkeri Compensation Insurance orecedi0ed copy thereof(See.IBIW,I.mb CJ which PARK FEE YN
covers all emplo ads under this permit. RIiC1iIPT p
> GAS-EA.SYSTEM- INCA OUTLETS
p BUILDING DIVISION FEEB
Company
❑ Certified copy is hereby furnished. OAS-9A.SYSTEM-OVER 4(EA) PLANCI PECK FEE
❑ Codified copy is filed with the city inspection division. GRI? SI✓[NDUSTRLWAST[i INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRRASETRAP SOILS THE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIW) SHWER-SANITARY-STORM EA.2001,17. EFRGY FEE
or less]
I cotifythm in the performance ofthe work for which this permit is iss.W,Iahall WATER HEATER W/VENT4'-LECfR
not employ any person in it,manner so n to became subject u,the Workers PAID '
z Cnmpemmmn Lowsof California. Date WA'I FR SYSTEMrrREATING 'Dam Receipla
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. 10 IAL
Cot become subject o the Workers Compensation provisions of the Labor Code,you must
� > forthwith comply whibsuch provisions or this permit shall be deemed revoked. BUILDING FEE
1 (� CONSTRUCTION LENDING AGENCY - SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
U O the work for which,his permit is issued(Site3097,Civ.C.) O ELECTRIC FEE
Lender's Name
�F Linter',Address - - QTY. MECHANICAL PERMIT FINE. PLUMBING FEE
U 1 cedlfy that I have read Ma applicetimt and state that the have inform lion is
W correct.l agree m comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MECHANICAL FEE
� buildingcunstructiol.-it hereby auNorimrepreaentaivesofd is city momer,upon the CONSTRUCTION TAX '
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MSCI 1.
(We)agree to save,indemnify and keep hornless the City of Cupcnino against
liubilities,judgmonts,costs and expenses which may in any wayacctveagainauuid City AIR I[ANGLING UNIT(TO 10,010 CFM)
thcgm ingotN' it.
Is ` AIR HANDLING UNIT(OVER 10,000 CFM)
Sie urenf APPLcanVCnnvucmr Ddc HXHAUSTHOOD(W/DUCII
PAID
HAZARDOUS MATERIALS ISCLOSURE HIiA'TWO UNIT(TO 100,000 BTU) Date Receipt#
Willthe the Coleman Municipal
Code,Catnsroreor handle hHmNh and Safety
HEATING UNIT(OVER 100,,%7 BTU) TOTAL:
as defined by the Cupedino Municipal Code,Chapter Y.@,end the Health and Safety
Code,Section 25532(a)? _ V6NTBATION FAN(SINGLE R6SID) ' �w
❑Yes ❑No
Will the applicamurlumrcbuildingoccupam use uquipmemordevices which emit
BOILER-COMPOLPOR 100,000 BTU) ISSUANCE DATE
hamidous air comaminants as definN by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?I ❑Yes ❑No
NGW RFSIDF.NTIAL MECH. SQ.FT.
1 have read the notorious materials remittee s under Chaptar 6.95 of the r !9 e I
California Health&Safety Code,Sections 255(15,25533 and 25534. l undere(wd that
f lAc building does not currently have amount,that it is my responsibility to notify the '
ccupnm mf the ralulrcn,en,e wM1lch must ho me(prim to iseuanco ofu CeniOmm of
occupancy.
Owner or authodm l agent Dae TOTAL: ISSUED R.Y.
OFFICE