25133 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
2533
CITY OF CUPERTINO •DTIC• PERMIT No. I
APPLICATION/PERMIT PLUMIIING-MNCIIANCAI. 1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS::w`.i ` SANITARY NO. APPIICATIIOO/NSSUBBMITTALDATE
D �^+ �� Vv UNIT# LOT# �� �/ 1�3
•OWGRS NAM : PHONECONTRACTOR'S NAME: LIC NO: N/C CONTROL
ARHITECGEER:
LIC NO: ADDRESS: ❑
CONTACT: PHONE:
1 BUILDING PERMIT INFO
5�/e /�s a � / QTY. ELECTRIC F T FEF
G/WLn 1 p6`-zz7 LDG ELECT PLUMB MECN
V _D/ r PERMIT ISSUA CE _J O El C] Ei
LICENSED CONTRACTOR'S DECLARATION pppLlpy PNng1 JOB DESCRIPTION
pyz Ihcrtby affirm lhmlem licensed undcrprovisinnsofChepmr9(commenting with
�i100 Section Tfglf)of Division 3 of the Business and Professions Cod,andmy license is in PA
a,,,, fall Liam. and err«L ��r
p,ZIL Licenu Clam Lic.# UP
.<0Date Conn.. 1 PS
FD.z ARCHITECTS DECLARATION SQ.FT,FLOOR AREA S/SQ.FT.
02 y W 1 understand my plans shall be used m public r«otds. 1000 AMPS
F❑ too
a
4 ,z„Jj Licensed Professional SIG EIRCRU
5 2'< OWNER-BUILDER DECLARATION ECTAL CIRCU LSC.
�xx'OyU I hereby offrm That 1 am exempt from the Convectors License Law for The
W 3 O vFi fallowing reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE FIST. \ a
F1 y which require a permit to canstmd slmr,improve,demolish,or repair any structure �V
prertoitsI--vane,also tryuireslheapplicantforsuchpermanifileasignedromosst POWER DEVICES
O
that he is licensed pursuant to the provisions of the Contractors Limme law(Chapter
L 9(commencing with Section 9000)of Division 3 of the Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
y�_y or that he is exempt therefrom and Ne bmiafor the Nleged exemption.Anyvidauonof VfLETS SWITCHES FIXTURES
z Section 7031.5 by any applicant for a permit subjects The applicant a civil Penalty of2AS
p❑EO not more than five hundred dollars($SW). NEW RESIDENTIAL ELECTRS .
5m 1,asownerofthepmny,mmyemplo mswithwagesmthcirsolecompcnsauon. Q FT.
[Ip STORIES TYPE CONSTRUCTION
d willdothework,andthe swctureis not irtmndedaroffered force «70 ,Business
and Professions Code:The Contractor's License Law dims not apply to an owner of
Property whobuddsor improves thereon,and whodues such workhimselforthrough his OCC GROUP RES.UNITS
wnempby«s,providedlhat mchimprovervems orenotimemledlo fM
faformn.IL
however,the building mrimproversem is sold within one year ofcompletion.Ne owner- TOTAL: 2,
builder will have the burden of proving that he did not build or improve for purpose of
side.).
❑ I,asownerofthepmpeny,atnexclsivelycontmctingwiNlicensedconvaciomm QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(S«.7(344,Business and Professions Code:)'The Contrmtors
License law does not apply to an owner ofpropeny who builds or improves thereon,and PERMIT ISSUANCE
who counters forruch projects with acommea (s)licensed pursuant tothe Contractors
License Law. gLTEft-DRAIN@VFM-WATER(EA)) FEE SUMMARY
❑ 1 am exempt under Sec. ,B @ PC for this reason BACK FLOW PROTECT.DEVICE UT,IDE F::
SANITARY Y N
Comer Dem p INS _ OOF CON RECEIPT
#
WORKMAN COMPENSATION DECLARATION AA SCHOOL TAX Y N
❑ Ihcrcby affirm thatlhnvc ecenifate orconuntm self-menneoracline leo PE RAP RF.CEIPI'#
Wwkeri Compcnmtion lnxurana on certified copy therwf(Sw.380O." hick PARK LER Y N
covers all employees under this permit qr IS -1 4 U EfS RECEIPTp
Policy p dS BUILDING DIVISION FEES
Company GAS-EA. Y (1'
Cl Certified copy is hereby famished. PLANCIiECK FEE
EICerifieleopy is fled with the city inspectiondivislan. L TAI 1C
OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section nond not he completed ifthe permit is foronehondrtd dollars($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les.)
I certify That in The performance ofthe work fm which Nis Permit is issued.I"I WATER HEATER W/VENT/ELECTR
not employ any Forman In any manner so es to became subject to Ban Workers' PAID 3
Compensation Lawenf California. Date WATER SYSTEM/TREATING Dole Recmp#
Z Applicant
z�7P0 NOTICETO APPLICANT:If,after making this Ceniftcateof Exempuaa,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-t (6 hccome mbjen to the Worker's Compensation provisionsafthe Labor Cade,you muss ^
1� 7 forthwith amply with such Provisions or this permit shall demandFE
Ix,derevoked. BUILDING E �sa4
z CONSTRUCTION LENDING AGENCY SEISMIC FEE U
I hereby affirm That there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE {-�
U O The work for which this Permit is issued(S«.300.Civ.C.) 32•Z'
Lender's Name
U Lenderm Addrom QTY. MECHANICAL PERMIT FEE PLUMBING FEE
�
1 certify Nat I have rtait NN
is ap,fcanion and state at Nab
ore move inPortnetion is MECHANICAL FEE" 1
crect I agree In comply with all city and county ordinances and stain laws relatm ing PERMIT ISSUANCE
building construction,and hereby amhmrlx representatives ofthisciry teenterupon the CONSTRUCTION TAX
U z olvnve-memioned property for inspection purposes. ALTER OR ADD TO MECH.
(WO agree to save.indemnify and keep harmless the City of Cupertino against
liabilities,rydgmrnts,costs and expense which may in my way acme against mid City AIR HANDLING UNIT CTO 10'"CFM)
in consequence of the granting of This permit.
/ AIR HANDLING UNIT(OVER 10.(100 CFM)
Stg&TA/P It! ontmcmr ss Date EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Date Receipt#
Will the applicant or future building occupant atom or handle hamrdous material
e HEATING UNIT(OVER IOO,000BN) TOTAL: SIXJ
defined by the Cupertino Municipal Code,Chapter 9.12,and the Dumb and Safety
Code,Section 25532(ap
❑Yes ❑No VIiNTlLATION FAN(SINGLE.RPSID)
BOILER-COMP QIIP OR 100,000 BTU) n S1�A�CUATE
Will rhe npplicantor fmurcbuilJingoecupom time Wuipmentor Jeviceswhichemit P A
hemrdous car contaminants as def om by the Bay Area Air Quality Management BOILER-COW(OVER 100,0110 BTU)
District?
13n
1
Yes ❑No NEW RESIDENTIAL.MECNI11 s+. SQ.FT. M B V /7 '1993
I have reed'be Thomism,.,costs requirements under Chapter 6.95 of the 1'I
California Health @Safety Code,Sections 25505,25533 and 25534. 1 understand that CITY Vr' v�ren111VU
it the building docs not currently have a tenant that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
0ccupricy.
Owm,ea authrrired.gem Dose TOTAL: ISSUED BY: SCC