25600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .- Al l . PERMIT NO.
APPLICATION/PERMIT PLUMBING.'-MECHANICAL 25600
BUILDING DIVISION IIUII.DING PROJECT' H3N
IDENTIF'ICAT
BUILDINGA@DRESS: `1 r/� yga, 1 SANITARY NO. APPLICATION SUBMITTAL DATE
X03-17 V15rA KNOLL 13L UNIT is LOT is 104
NERSNAME: PHONE: NI'RACIOR'S NAME- LIC NO:
Lu AM SrAI(S 2152CO 57 OW mex N/C CONTROL#
CHI'1'ECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE:
QTY. ELECTRIC PERMIT EEE Bl➢LDING PERMIT INPO
SLUG CLECP PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. TOB DESCRIPTION
Ma4z Ihembyuffirn that lam licenaedtaxim,rovlsionsof Chapter9m
(comencingwith
1400 Section 70001of Division 3 of the Business and Professions Code,and my license is in PANELS M�I
full force and effect. /w
License Class Lic.M UPT02MAMPS
FDoo Date m
Coructm (I(NI
201-IAMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZOti2 ARCIIITF.CTS DECLAMATION OVER 1000AMPS
FQ I i ndenmad my plane that be used as public records. iss �/►f
_i SIGNS ELECTRICAL C_YV) �JVf
•� Licensed Professional
CC OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
aappGG,,Oy V I hereby affirm that I um exempt from the Contractor's License law for the
n+3 y following reason.(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR POLE INST.
which requires a permit to construct,mer,improve,demolish,or repair any structure
uZzTER
prior to its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
ty pthat he is licensed punuam to Ne provisions of the Contractor's License law(Chapter
d oPd 9( mencin000
g with Section 7 )of Division Tefthe Boston.and Professions Code) SWIMMING POOL
Pd
comELECTR — QjA���LUATION
.c.2. or that he is exempt thercfmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FI%NRFS
FZ_a Section 7031.5 by any applicant for a permit subjects the stil en to a civil Penalty of v
a more than five hundred ANlars NEW RFSIDP.NTIAL CLEC R _SQ.FT.
ado �Lmownerofthepropeny,ormyemployeeawith wagmastheirsole compensation. STORIES TYPE CONSTRUCTION
will do dresork,and the structure isnot immudedornffered forale(Sec.7044,Business
and Professions Code:The Convector's License Law does not apply to an owner of
propm,y whobuildror improvesther acand whodmessuch work himselforthrough his OCC.GROUP RFS. HITS
own Infers,providecithatsuch imprommemsumnot imendedoroffered fmsale.If,
h wever,the building or improvement is sold within one yearnfcompletiun,the owner
builder will hove the burden ad that he did not build or improve far u f 'TOTAL:
proving prov purpose
.1e')' Q1 Y. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I•ae ownerofth(Sm.7(M. usimaively cam es,io s licensed comveetonm
comwa the project pplytomw operef a and Professions Crude:)The Contractor's
whocotawdcesnm apply ownerofpropeny whobed pursimpaves Comminend PERMIT ISSUANCE
whence Us.fmsuch pmjemawith acuntrucror(s)licenced pursuant to Contractor's ALTER-DRAINA,VENT-
Licenae Law. WATER(13A) FEE SUMMARY
❑ 1 nm esempt under Scc. ,B&P C for this reason BACK FLOW PROTECT.DEVICE. SANITARY Y OUTSIDE EvEll
N
Owner Date RECEIP #
DRAINS-FLOOR,ROUP,AREA,COND.
WORKMAN COMPENSATION DCCLARATION SCHOOL TAX YN
❑ Thereby affirm thatlhaveecenificaa of versant toself-insure.on cenificme of rIXTURBS-PER TRAP RECEIPT#
Workers'Cam(tensmion lnsuruncmreccrtifieJ copy thercnf(See.3g00,Lab C.)which PARK FliE YN
covers all employee's under this pmmit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION ETES
Company
❑ Certificdcopyisherebyfuaished. GAS-PA.SYSTFM.OVF.R 4(FA) PLANCIIIiCK FEE
❑ Ccomed copy is filed with the city inspection division. GRHASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not ed completed Brie permit is fm one hundred dollars;($100) SEWER-SANITARY-STORM PA.20017. IiNERGY FEE
Ieas.)
I certify that in the performance ofthe work for which this permit is issued.)shall WATER HEATER W/VF.NT/ELEC1'R
not employ any person in any manner to as to became subject to the Workers PAID
Compensation Lnwsof Califomie Data WATER SYSTEM/1'BEATING Ume Receipt#
Z
OO NOTICE TO APPLICANT:IL after making this Certificate of Exemption, h Id NEW RESIDENTIAL.PLMB. 5
ZYou should Q FT. OTAL:
(^" tq becomesubject comply
the such pre Compensation emit shallns fthe labareCode,oked. man
� ; forthwith comply with such provisions or permit shall be deemed revoked. BUILDING FEE
a L CONSTRUCTION LENDING AGENCY SEISMIC FEE `
ice. z Iberehy affirm that there it a construction lending agency for the performance of
U OI-� the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEC
V Lcndeis Name
O Lenders Address QTY. MSCI IA NICAL PERMIT FEE PLUMBING PCE
I certify that 1 have mad this application and state that the above information is
cored.la to coat with all cit and rdinances and same laws mining to PERMIT ISSUANCE MECHANICAL FEE
gree comply yon yrs g
builmnounncesed Popert hor impec,dim ,presenafivm of Niscity toemerupon the
U ,z adrve�memimned properly for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)ago.tat s e,' damnify and keep heatless the City of Cupertino against
IiabiI Ii<s.jad m index h' in any way seemeagainct said City AIR HANDLING UNIT(TO 10.W CFM)
a. bn tog n p-
AIR HANDLING UNIT(OVER I LW0 CFM)
tgnemreofApplicam/Conua or Date EXI IAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,010 BTU) Dae Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM,"BTU)
Cable,Section 25532(n)7
❑Yea EJ No VENTILATION PAN(SINGLE RESID) 1
Will he applicam or(mumbuildingoccupam useryuipmem ordevica whi<hemit
BOILER-COMP(31TP OR 10,010 ITII) ISSUANCE DATE
.mrsrdous air contaminants as defined by dte Bay Am Air Quality Management BOILER-COMP RIVER IUQOW BTU)
Dia et? IT�g
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FP, P A I D
E have read the hmtWom materials requirements under Chapter 6.95 of the
California Death&Safety Code,Sections 25505,25533 end 25534.1 understand that OCT ���
if the building does not cunendy have a tenant,that it is my responsibility to notify the
occupant of the requirements which must he met prim to issuance of A Cenificate of
Occupancy.
0
Owner ter authorized agent Dae TOTAL: ISSUED BY: 111c I I WU
OFFICE