25171 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION PERMIT NO.
APPLICATION/PERMIT PLUMBING-MF.CAANI
BUILDING DIVISION 1BUIIAING PRDJI3C'T IIIEM'IFICFICA'I'ION
BUILDINGDIR�IEISS: 1L.II/,r 1I 11 SANITARY NO. APPLIC1ATIIOON SUUBB,MITTAL DATE
1 ky 3/ IS 1/ UNITM I.OTM `sal y�(Q
't 5 NAMH: y pyli—� 0 vj' CO A BR'S NA S O 1�) LIC N60*3Nrc C111�"ONTvvvR01.NVVV
RCI It I L'Ui AiiNGINEER: LCNO: ✓ A RESS: 'sJ1"
X631 vl�P S� gS12 ❑
'ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT'INFO
( .0 n Q �I'f �I BLDG ELECT PLUMB MECH
O �S ff F� s'[�'(J I 1^ /�f�2 PERMITISSUANC'H ❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESC 1 ION_
#0..z Ihamby affirm than l am licamadunderpmvisionsofChapter9(commeneingwith s 'I-w\
y00 Section 7000)of V full to.and affecttV//)n iston flhe Businesy.¢nd Ofessiom Code,and myliceveis in PANELS
UP T02fIBAMPS �Q/g/�I��� I1'/Nlyy I p
F oo Licen Its VV'1 Lic.p 5q1--S��� C'
y 0. Date Cnnracm 201-1000 AMPS
z Oy!-4 ARCHITECTS UE LARATION OVER 1000AMP5 t SQ.FT.FLOOR AREA $/SQ.fT.
CZ-0 I understand my plans shall be used as public records. - - u s N
(_lm W SIGNS ELECTRICAL .-
Llcensul l'rzdessional
OWNER-BUILDER from
m the Contractors
SPEC4ll.CIRCUIT/MISC. % bVd R
yx�4F I hereby affirm that 1 am exempt frim she Conlrnetor's License Law for the
sr+3 W wQ following reason.(Section 1831.5.Business end Profession Code:My ciry orcounty 'TEMP.METER OR WST.
u,ON J which requires a pemui to construct,otter,improve,demolish,or repair any slructme DATE
DATz
gp-7 prior to its issuance,also requires the applicant for such Permit file a signed statement POWER DEVICES
�p that he is liccnud pursuam to the provisions of she Contncmrs Liaise law(Chapter
9
9(commencing with Section 70(K)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
XW-.m anhmheisexempnthcrefmmand thebminfortheallrgedexempuon.taiit,lationaf
p-. a Section than by a undredicwtrs($50rmil subjects she applicant to ecivil fwnelt of OUTLHI'S-SWITCHES-FIXTURES
J not more than five hundred dollen(5500). NEW RESIDENTIAL ELECTR _SQ.FT.
_o Cl do tI.mhe
work,
thesperty,er myempinded mutilated
044.Business STORIES TYPE.CONSTRUCTION
will dorhewons mtdCode:11a Contctureractor's
License Law
apply
to an Business - /I
and Professions lds or i ILe Ca therson,License law dens or apply m r t owner of
ownparam wheas,pr orimprovesch improvements
who rum not suchworkthroughhis
empinyeca,proviJrdthatsen improvements menet eardrmoffered forside.If,
owmar. OCC GROUP RfS.0 ITS
however,the building uimprovement ixsold within one year or improve
for Neowner- TOTAL:
builder will have the burden of proving that he did not buil)or improve fm puryose of
alt).
11I,nownendthe Property,am exclusively contracting with licensed contnaonm QTY. PLUMBING PERMIT FEE FLOOD LONE APN
construct the project(Sec.1814,Business and Professions Cade:)The Contractor's
License Lawdoesnosapplysn anownerofproperty,whobuildsorimproves Thereon.and PERMIT ISSUANCE
who contracts forsuch projects with a contractor(s)licensed pursuaauothe Canwesor's ALTER EA FE[i SUMMARY
License law. ( )
❑ I am exempt under Sec. ,B&P C for this masonOUTSIDE FEE
BACK FLOW PROTECT,DEVICE
Owner DateSANITARY RECEIPT#
TIN
DRAINS-FLOOR,ROOF',AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
I hereby con,shnn thmlhave
ance or ificamof consent
pytherof(Savum,at.Lab C.)me of
41 which FIXTURES-PER TRAP RECI!IPT#
karts Cmployeasiender this permit.
0ed copy thereof(Sec.Jg00,Lab C.)which PARK FEE Y_N
Poszn all employee's under this permit.Q I�q IObi'SD RBCF.IPf#
vl GAS-GA.SYSTEM-1 INC.40lITLETS
Policy It - BUILDING DIVISION FFFS
Company PW LA/AT GAS-EA.SYSTEM-OVER 4(IA) PLANCHF.CK FEE
❑ Gentled copy is hereby fumishul.
`Q Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF MEMPIDON FROM WORKERS' GREASE TRAP SOUS PER
COMPENSATION INSURANCE
Max action need not hecampleted ifthe permit is foram hundred dollars($100) SEWER-SANITARY-STORM F.A.2WFf. ENERGY FEE
or lam.)
I cattily Nal in the performance of the work for which this Permit is issued,l shall WATER HEATER W/VI3NT/ELEC'IR
not employ any person in any manner so m to become subjat an the Workers' PAIVELE�RICFEE Campensstionlawsof Califom3a. Dam WATER SYSTEMITRFATING Receipt#
O z Applicant
Z 0 NOTICE TO APPLICANT:IL after making this Certificate of Eaemption,you shoodd NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
� f4 become subject to the Workers Compensttion provisions of the Labor Code,you must
� > forthwith comply with such Provisions or this permit shall be domed revoked. �y
aQ CONSTRUCTION LENDING AGENCY
z I hereby affirm that is a construction lending agency for the perforrimnce,of TOTAL:U Othe work for which this permit is issued(Ser.3397,Civ.CJLembo,eader's NwncUlancr'e Address QTy, MECHANICAL PIiRMI'I' FF.
1 anify than I have read this application and state that Ne above information u
>"' W0. c real.fa rue to cote I g MECHANICAL FEE
g comply all city and county ordinances end slue laws mlatin m PERMIT ISSUANCI3
buildingconsmiction,and hereby uuWorirc represenmdvaof thisciny to amer open the CONSTRUCTION TAX
U z above-mentioned progeny for inspection par,osee. ALTER OR ADD TO MECH.
(We)agree ,,auva,indemnify oad keep harmless the City of Cupertino against
habit ties,judgmcros,coact and expenses which may in my way accrveagainst said City AIR HANDLING UNIT(TO I B"CFM)
Ins of the rantim (This e m I Y f`J s 1/15
I tl
Tow AIR HANDLING UNIT(OVER h%000 CFM)
S mature fApplicuni/Con actor I Date EXHAUSTHOOD(W/DUCT) PAID
IIAZARDOtISMATERIAI.SDISCI.OSURE HEATING UNIT(TO 108,000 BTU) Dase Receipt#
Will the applicant orfuture building occupant stem or handle harardnm materiel HEATING UNIT 1(q,(KKI BTU) '1'OTN.:
as defined by the Cupertino Municipal Code,Chapter 9.12,and The f health and Safety
Code,Section 25512(a)1
❑Y �No TIVENLATION FAN(SINGLE RPSID)
Will he orfmurebuildingoccupanl use equipmemordevicem which<mit
BOILER-COMP(JIIP OR 100,fH10 BTU) ISSUANCE E
�halardna9 air rontaminanls m defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.00E BTU)
OisViCl'7 1,
13 Y., aX No NEW RESIDENTIAL.MECH. SQ.FT. p
I have mead the hazardous materials requiremenct under Chapter 6.95 of the 8
Calilintra Health&Safety Code,Sections 25501,25537 and 25534. 1 understand that �1AN d
if the building des oat currently have a tenam,that it is my aspovllllyy. to otify the
noncom of k� cyu'c ems w b mu mm pr r to iesuan�e(f a Ce feat#of
Occupancy.! 1 /I � (
OwnersuethnrixeJagem A4 rte TOTAL: ISSUED BY: