25530 J
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO It- AAAA RICA[ PERMI'TNO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL. C C O O
BUILDING DIVISION BUILDING PROJECT IDHNTIFICATION J J J
BUILDING ADDWSAA
S: �/I� SANITARY NO. AAPPPLIC�11ONSUBMRTALDATE
QzIol y (�� T# LOT# —yam{
OWNE NAME: NE: ACNO: V
3
`I C
N/C CON I KOL#
CHI ECT/ENGINEER: LIC NO: ADDRESS: ❑
"UNTACI': PHONE: BUILDING PERMIT INFO
r QTY. ELECTRIC PERMIT FEE
B1yDG ELECTPLUMB MFCIi
PERMIT ISSUANCE J/i 0
13
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
GCZ I herebyalErm that tum licensed underprovisions of Chapter9(commencingwith
I400 Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
FF{�I full force and effect. 11P T02tq AMPS ■VF9�Hs�/sJ 1� ��V
a
QUZzW license Class Lic.p
ce 6 a Data Contactor 201-1000 AMPS
Fye ARCHITECTSusedDECLARATION / IY ESQ T.�OO L� _ ySQ:
1 ONEOVER IOW AMPS Itl! IY11V'1 QAr e^V,
0 Z— I understand my plans shall o used an public records.
,4l
, SIGNS ELECTRICAL
gY Licrnud Pr.Ibssionel n o p Q
C OWNER-BUILDER 51'F.CIALCIRCUIT/MISE. ouVe yTy s•({
°�OaU 1 hereby M.that I am exempt from the Contractor's License Low for the
W 3 O oa following reason.(Section 7031.5,Business and Professions Cade;Any city or county TEMP.METER OR POLE INST. A O
I=��n which medial apermittoconstruct,alter,Improve,demolish,or repair my structure Il O
f Yn prior to its issuance,alsorequirn the applicant for such parma to file a signed statement POWER DEVICES
0 that he is licensed pursuant to the providom,of the Contractor's Licenu_w(Chapter
Ke� 9(commencing with Secti.n]0007 ofDivisi.nJolthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
,t 2, or that he is escmpttherefronmil the basis fm the alleged exemption.Any violation.1'
Zp❑Q Sectio e
7031.5 by my applicant for a prnitsubjects the applicanm
t a civil penalty of OUTLETS-SWITCHES-FIXTURES
G0 tato.than five hundred dollars($SW). NEWRESIDENTIALELECTR —SQ.17.k no,
Lasowrt F,,e hundred
yaswith wegnastheinolecompensmian, Q STORIES TYP CONSTRUCIWN
a3� will do the work,and theavumufe isaot intended.,offered forsaleSem.7M,Business
and Professions Cade:The Cmdba la License Lew dams not apply r.an owner of
property wm builds c r improves there..,and who d.ex such work himself ru ibal his
employees,MovidMd isuchimpmvemememmnotintendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yeeofcompledom,iheowner- TOTAL:
builder will have the burden of graving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE
❑ i.aaowner nftheprnperty,am emdnsivelycolrscOng with licensed convecmmto FLOOD ZONE APN
consume the project(Sus.7044,Business and Professions Cade:)The Convector's
LicenseLawdems not upptyroan owacrofpropeny,whobuildsmirhowesthereon,and PERMIT ISSUANCE
whoconamen for such projects with acontmetors)licensed purmantlothe Contractors
License law. ALTER DRAIN&VENT-WATER(FA) FF.E SUMMARY
❑ 1 am exempt underSa. .B&PC fru this reom BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y_N
Owner Date DRAINS-FLOORROOFAREA,COND. RECEIPT It
, ,
I WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have acenificamafconsenuoulLinsure,oracertlficate ofRECEIPT#
pr'%TURES-PIR TRAP
Wnnken'Camprnsationlrasumnce orncenificd copy shere.f(Sec.78011,Lab C.)wM1ich PARK LEE YN
covers all employee's under this Permit. GAS-IIA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy#, BUILDING DIVISION FEES
Company OAS-EA.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ Certified ropy is hereby famished.
❑ Certified ropy is filed with the city inspection division. GREASPONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need drubs completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I curif don in the perfrumance of the work for which this permit is issued,Ishall WATER HEATFA W/VENT/ELECPR
not employ any pato.. in any manner m n m become subject to the Woraral' PAID
Campenmti.m Lawsof Celifomim. Date WATER SYSTEM/TRRATINO Data Receipt
zz Applicant
O NOI ICE TO APPLICANT.If,mfer making this Certificate of Esem i ushauld NEW RESIDENTIAL PLMB. SQ.FT. TOTA
p tan.e,
become withsubjectoro it Worker's Compensation bruprovisionshof theLaborEvoked. must
a , boMwith comply with such pmvisionx or permit xhell be deemed revoked. BUILDING FEE
F CONSTRUCTION LENDING AGENCY SEISMIC FEE
ow
V z Iherehyafftmtthmuhe.iso commuctiod Imdingvgedcy bertha perfomnceof
m
O me work far which this permit is issued(See 3097,Civ.C.) TOTAL: ELECTRIC WE
Lenders Name
O P Lender's Andreas Q'TY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify Had 1 have must this application and souse that the move information is MECHANICAL FEE
>. Wcorrect.lagree.comply with roll city and county ordinances end stem laws relesingm PERMIT ISSUANCE,
mildingeousvuction,and hereby outhorre representatives ofthis city to enter upend¢ CONSTRUCTION TAX
U Zaovementioard property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabduma,jud oco andexpenses hi It may inany way osmiumegjmt said City AIR HANDLING UNIT(TO 10,000 CIM)
accelerate,
n mnuque eo
,a'r
ga(th'
AIR HANDLING UNIT(OVER IR"CPM)
Signkaille rKipplRanucmamcda, Data EXHAUST DOUG(W/DUCI) PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt it
Will thempplicant or future building occupant mres or handle huandous material HEATING UNIT(OVER FOR"BTU) alrfAL:
as defined by We Cupertino Municipal Code,Chapter 9.12,amt the Health and Safety
El No
Code,Saxon 25532Ia)P VENTILATION FAN(SINGLE RESID)
❑Yee
Willsbea licantmbusure huildin Deco um one BOILER-COMP(3HPOR 100,(1(1(1 BTU) ISWANCE DATE
pp g p Amu Air Quality
Mulaghemit til p
ofimie.ua it comatninanm as de(ned by the Bay Area Air Queliry Management BOILER-COMP(OVER 100,000 BTU) W
istnaY Say
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.Ff. 4GL yam �9
1 have rad the baysrdous materials requirements under Chapter 6.95 of the Cary VX
Califamia Health&Safety Cade,Sections 25505,25533 and 25534.1 uadcrsmnd that to
if We buildin'dome not cual have a mount,that it is my responsibility to notify the ser
court of the requirement which moat be met prior to issuance of m Certifies.of
Occupancy.
Ownermmahmi><dagent Date TOTAL: ISSUED BY:
OFFlUt