25000 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINODD'mNix-KLLCrR[CAI PERMIT NO. 25000
APPLICATION/PERMIT PLUMBING-MECUANICAI,
BUILDING DIVISION BUILDING PROJECT IDEN'I'IFIC PION
BUILDING ADDRESS: - � SANITARY NO. APPLICATIONSU
O S1AI /11 /) K f `.0 PHONE: CON�CTpIl;.S N_ LIC NO:
F41M,(�.a{T, `�C"F{1w�, (J' e '�l,�,F��,L/.• N/C CONTROL
IARCHITECF/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
' QTY. ELECTRIC PERMIT PF:E BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
_ PERMIT ISSUANCE 11 ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm that l am licensed under provisionsm'Chapser9(commencing with
u100 Se,lum9Wm)nf Division Sof Ne Businessand Prime,,nons Code,andmy l license is In PANELS ' fk
FFy.WC fall house LicnseCitdeffect. UPTO20JAMPS G U �'�
F<n. License Class Lic.# 1
moa U.tc Contrncun 201-](hmAMPS '-
70NZ ARCHITECTS DECLARATION OVER IWO AMPS SQ.FT.PLOORAREA - $/SQ.FI'.
0'Z^D I undcrstanA my plane sM1all he used xs public rccoNs. I
na W SIGNS Ii1,LC1'RICAI. 1
<c,ia�� Licensed ofe lomat
OWNER-BUILDERDECLARATIONSPECIAL CIRCUIT/MISC.
XO0 F I hereby affirm Thal I am aempl from We Contractor's e:Any ciLawty
o for the
W'3Wrp following reason(Section 7031.5.Business and Professions Cale:Any city or county TEMP.MUTER OR POI,P.INST.
�&�g which require%aperouttoconstruct,alter.improve,demolish;or repair any structure
gip. pdo,to its issmaacs,.I.n thea licant fmsuch tm fin.,i ed statement POWER DEVICES
quires PP Practo B^
p p that he is licensed pursmm to the provisions of the Comrvemr's License haw(Chapter
ta.Wo�' 9(commencing with Section MID)of Division 3 aT Bu
the siness 0 Professions Code) SWIMMING POOL ELECT RIC
W_y or he is exempt herefmm and the hasis for alleged ewmptiom.Any incontinent Of1Tl FT'S-SWITCHPS-FIX'IVRFS
HIMQSection 7031.5 byany applicant for.permilsubjeGa the applicant to a civil Penalty of
O nn oreWan fivehundredd.11m,($500). NEW BESIDES HAL ILECTR SQ,FT.
n=n 1.11tbepmprty,ormyemployeeswithwagesastheirsolecomNnsation. STORIES '1'YPIi CONSTRUCTION
3 ill do the work,omit the slrncmru is amt intended proffered formic(Sce.'/044,Business
d Professions Code:The Contractors License Law docs not apply to an owner of
mpertywhobuildsorimpmves thereon,and whodoessuch work himselfor0rough his - OCC GROUP RTS.UNITS
awnempinyses,provided lleasnch improvemmatsmenot Intended moffeed f^rsnle.If,
however,the building or improvement is sold within oneyearofcomplehim,the owner- TOTAL: '
builder will have the burden of proving that he did at build ar improve for purpose of -
me.).
❑ I.asowneroflhepmpeny.amexclusivelyconuactingwiWlicenxdconmtomm QTY. PLUMBING PERMIT 173E FLOODZONH AI'N
instruct the project(Sec.7044,Business and Professions Cale:)The Contractor's - -
License Lawdoesnot apply loan ownerofpropcny whobudds or improves thereon,and PERMIT'ISSUANCE
who contracts forsuch projects with ucontr cmr(s)licensed pursuant to the Commuctors
License Law. ALTER-DRAIN&VENT-WATER EiA) ME SUMMARY
❑ I em exempt under Ss. ,B&P C for this moron BACK FLOW PROTECT,DEVICE OUTSIDE PIE
SANITARY Y N
Owner Date RECEIPTp
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION - SCHOOL TAX YN
❑ Thereby strum ohm lhuveu<mificutc of amsenunsdf-insure,oracenifimm ofRECIi11T#
Wnrkers'Grmpensmion Insurance cru certifieJ copy thereof(See.Jtl00.L.h CJ which
FIXTURES-PER TRAP PARK FP.Ii V N
covers.11 em la ice's undcnhis t. RECHIPTI,
p Y Pc^^' GAS-EA.SYSTEM-1 INC.4OV1'LIi I'S
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCI IHCK FEE
❑ Certified copy is hereby famished.
❑ Certified copy ie ElcJ with We city inspection divieinrt GREASUINDUSTRI.WAST INTERCEMOR GRADING FEE
C17RTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPHNSATION INSURANCE
(This section need not be,completed ifthe permit is for me hundred dollars($100) SEWER-SANITARY-STORM EA.200FTENERGY FEE
or J
I ceolfythm in the peffmmvtce of the work far which this pmmit is ismed,l shall WATER HEATER W/VENI'MLEIMR
not employ any person in any manner so as to become subject to the Workers' PAID
Z
nt
CmaNnsation Lnwsof Califomia. Date WATI7R SYSTEMfIRPATING Date Receipt#
Applica
Z0 NOTICE TO APPLICANT:If,a0er making this Cmilicum of Exemption.you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
rU) became mbiecna the Workers Compensutinn prnvisionsnf We labor Code,you must
ty. forthwith comply with such provisions or this Permit shall be deemed revoked. RU LDING FET?
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them Fs n corewctwo lending agency far the performance of
the work for wh'mh this permit is issue)(Sm.3119],Civ.C.) TOTAL: ELECTRIC FEE
'� Lenders Name
OU Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify to.t 1 have lead Ibis application and some that Ne above information Is MIiC1FANICAI.1'I?C
correct.lagrce mcomply with ell city and county ordinance end sate lows rtlating tat PERMITISSUANCE
�-' huildingconsvuction,anJ herehy nuthmize reprernmtivcs of Wis city reenter upon We CONSTRUCTIONTAX
V Z above-mentioned property,for inspection purposes. ALTBRORADDTOMECIL
Doe)agree to save,indemnify and keep harmless the City of Capinino against
hatolities,judgn emus and espensea which may in any wayxcerueagainst said City AIR HANDLING UNIT(TO 10,0110 CFM)
one. o para ,of this pertni AIR HANDLING UNIT(OVER]0,q0 CPM)
. gmamte9f Applican un ter ¢ EXHAUST HOOD(W/DUCT)
/L PAID
HAZARDOUS MA'I'Ek1ALS DISCLOSURE T a HEATING UNIT(TO IOII INTO BTU) Date Receipt p 1.
Will the applicant or Tante building mcupem stem or handle hat. dons mat Ine
nx Jc0naA by the Cupertino Municipal TO
Cade.Chapter 9.12..6 the lleath unit Safety HEATING UNIT(OVER 100,(100 BTU)
Cade,Section 25532hm? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(311P OR 100,110()BTU) ISSUANCE DATE
Will theapplicandnfmmre buildingoccuWm uxeyuipmem ordevitts which emit
'luemedous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID
DisticY? ❑ _Yes E)No NEW RESIDI?MTIAf.MMECH. SQ.F1'. P
1 have read the hazardous materials requirements under Chapter 6.95 of the APR 26 1993
Culifarniu Heahh&Safety Cade,Sections 25505,25533 and 255]4. 1 understand mat
if the building does not currently have u nmant,Ihat it is my responsibility m notify the /s
.up.,of the requirements which must be ior sm
met prm iance Ofa Certificate of vIV eY (;Ur H
Occupancy. if
Owner Or uuthomcd agent Data ISSUED BY: