25629 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .Dace;,mincrRICAL PHRMITNo.
APPLICATION/PERMIT PLUMBING•MECHANICAL 25629
PUILDING DIVISION BUILDING PROJECTIDENTIFICATION
DING ADDRESS NiL �OIr1S SANITARY NO. APPLICATIONSUBMTALDATE
O �/, uNraa
Iu •� ��E{3
OW ERS NAME: PIIONI?: NTRA OR-S NAME: LIC NO: NIC CONTROL
!�2 T hr E PK to W -41
ARCHITECT/ENGINEER: LIC11`31 e— 317— 5.6'(,g
CONTACT: - PHONE:
QTY, ELECTRIC PERMIT FET. BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
IPOO Ihereby of
mision that I 3 ofilm sNunss and
irifesions Code,and
(crmmrncise with /� SL%C)L A�
00 Section 70011)e f Division J of Ne Business end Profusions Cade,end my license Is in PANELS r` VJ
R�j full force end cffut. -Q^,/ y79G 1 UPTO2013AMPS
CZ License Class U Lica
oo ZO—Rw4 P Cnntmott 201-1000 AMPS 0
Z
Ow ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PI'.FLOOR ARCA S/SQ.PT.
WO Z—OJ I undctstand my plans shall he used as public records.
SIGNS ELECTRICAL
Licensed Pru ssimnal
e
Sq tyyy6 OWNER-BUILDER DECLARATION SPECIAL CIRCUMMISC.
cai�S(OyF 1 hereby if,.thus 1 am exempt from the Contractors License Law for the
W 34m Following reusno.(Section 7031.5,Businesand Professions Code:Anycity or county TEMP.METER OR POLE INST.
iS OyQ which requims a permit to cohoodo,alter,improve,demolish,or repair any structure
nn-.� prior to its ismance.aso rtquires theapplicant for such pcmdtm fleavigned sammant POWER DEVICES
y)C 00 nd he is licensed puauanuo the provisions mf the Contactors[.I...taw(Chapter
adpff 9(cmannort,with Section 7")of Division 3 of the Business end Profcsaiom Code) SWIMMING POOL ELECTRIC VALUATION�•
Srthat ion 7031.5
03eeby any.fmmand the perist subj ellcgedexemptt to civiny l Pinion of OUTLETS-SWITCHES-FIXTURES ��
Qam..]031.5hy hudreddant fin$500).tsubjemenhe applicvnnoecivilpenaltyof Q
W pnm more then Ove hundred dollars(55010). a. NEW RESIDENTIAL ELEC 11 S .Fr.
❑ oomo endthepmructurbrm of intended withwagesusthe(Sax.camprnusiness —SQ.FT. TYPE.CONSTRUCTION
p, will dothewons C d e:The wreianors License
a w rd does not apply 7044,Bus
and Professions Code:The Contractors License Lew does not apply to an owner of
propenywhobuildscrur,mmasderevn,and whtrd.such work himselforthroughhis OCC.GROUP BE4.UNITS
wnemployee,pmvidedthatsuchimpmve martnotintendedorofferedforWe.IL
however,the building orimprovemenn is sold within one year of completion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
aale.).
C] 1,as ownerofthe property,um exclusively contracting with licensed convanora to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7094,Business and Professions CWc:)The Contractor's
License Lawdoesnot apply to anownerofpopeny whobuildsorimprovesthetun,and PERMIT ISSUANCE _
who contracts forsuch projects with aconnravions)licensed puaaanuothe Convectors ALTHR-D IN&VENT-WAT
License Law. gA t-_., FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fm this moronp
BACK ROW PR R. F.VICE �—' '"`
ITARY V N
Owner Data '\ .� T RECEIPT#
DRAINS-FLOG ;ROOF.ANI?A,CO
WORKMAN COMPENSATION
mofoon DECLARATION SCHOOL TAX Y N
❑ ers Co pens thnlhue acen.cards ermp,th,sent f(S"um,a Lab C.)ate Ofwhich FIXTURES-PER XP RECF.IPI'N
Workcr%Compensetion lnsuancemrecenifiW copy thertof(Sec.l8lp,Lab CJ which PARK E YN
covers ell anpbyce'e under Nis permit /3/ 4 7 U GAS-EA.SYSTEM-I RECEIPT p
Policy p ( BUILDING DIVISION FEES
°nr y S
sled copy is hereby ffurnished. GAS-FA.S STEM-OVER 4(EA) PLANCHECK FEE
Certified copy is filed with the city inspection division. GREASU'INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not beccmpleted ifthe permit is for one hundrddollaa T$100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify that in she Performance Of that work for which this permit is issued,l shall WATER HP.ATER W/VENT/ELECTR
not employ any person in any manner so as to became subject to the WorkersPAID
O z Compe
0 Ntion Lawenf Culifnnia. Date WATER SYSTEM/rREATINO Date Receipt#
Applicant
TICE TO APPLICANT:If.after making this Camftcate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
U) become subject to the Workers Compettation provisions of the Labor Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE `
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
V z I hereby affirm that hem is a conswction lending agency for the pmm
crfoce of
0 the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC FEE
(•k. Lenders Name
O Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have mad this application and sum Nat the above information is
;s- a
^ 1 coct.legreetocomplywithalldlymdcountymdinancesandlmwlewsmhdngw PERMIT ISSUANCE MECHANICAL FEE
F' rA building conswction,and hereby aulimiu repreunmtive ofthisciry,toantesupon the CONSTRUCTION TAX
L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
rte- (WO)agree no save,indemnify and amp harmless the City of Cupertino against
Habil itis,judgments,costs and expenses which may in any way rocrueagainatsvd City AIR HANDLING UNIT(TO I O,(gKI CFM)
in erase uence ranting of thio emit. /,G J7'� AIR HANDLING UNIT(OVER 10,"CFM)
Signnure of Ilcam)(7muanor Date EXHAUST HOOD(WIDUC)
PAID
IIA2ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOQ000 BTU) Date Receipt
Will the applicant or future building occupant store or handle hazardous materiel
as defined by the C.Pen to.Municipul Cede,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 23532(o)'t
❑Yes ❑No VENTILATION FAN(SINGLH RF.SID)
Will theepplicanwrfuturebuildingacupant usecquipmemmrdevices whichemdt
BOILER-COMP(3HP OR TOR"BTU) ISSUANCE DATE
• hahoul air comaminants as dented by the Bay Asa Air Quality Management BOILER 100,000 BTU)
District? �
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,17. Ire PA
1 have read The hazardous materials requirements under Chapter 6.95 of the (�q�
Callfamda Health&Safety Cede,Sections 255D5,25533 and 25534.1 undeamnd that (LS ICI'
if the building does not currently have a motion,thn it is my mspsnaibility to manly the x
occupant of the mquimmenis which man be met prior to issuance of a Cetificam of +� ^I I
Occupancy. V
NI11vu
Owner or authorized.,cut Date TOTAL: ISSUED IT'
OFFICE