25033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO —E1,1.1FRICAL PERMITNO. 2503 r�
J
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
I�U xll PROJN,CI' DENI'IFICAI ION
PUILDINGA DOJ ���'^ r`_ �� SANITARY NO. APPPLID
ICCATIONSUBMTALDATE
'I=, JJ((_�� 4rITVV IINITN LOT# A 7
RS NAML. pB�„Q� CONTRACTOR'S NAME: _— LIC NO: NIC V CONTC ROL#
NBC]Ill ECTIENIGINEER: LIC NO: ADDRESS: ❑
CONTACT:
PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEB
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �� J10�B�-DESCNIPTION
py�Z I hereby affirm that l am licensed underprovisionsot'Chuprer9(commencing with D
POO F Section]000)of Division 3 afthe Business and Professions Code,and my license is in PANELS
<UU full farceand officio. �f— ^
FZW License ClassLic.N UP T0200 AMPS 1U( I 0 \ A
mQy Date Comeactor 201-1000 AMPS l V
ZO,,Z' ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.Fr..FLOOR AREA S/SQ.R.
O Z^O I understand my plans shall m used as public records.
r tZI:W SIGNS ELECTRICAL
Liccnmd limfoxam d
JCWOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
iqqi�40au I hereby affirm but 1 am exempt from the Commmors License Law for the
t+sa Om following mason.(Section 2031.5,Business and Professions Cade:Any city or county TEMP.METIER OR POLE INST,
NFp-�N� which airlines u permit m construct,alter,improve,demalish,or repair my structure
r� prior to its issuance,also requites the applicant for such pomdt to file asignedsuwment POWER DEVICES
p"j O that be is licensed pursuam m the provisions of the Commcmr's License Law(Chapter
a a9(commencing with Section 7000 of D]vision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
�,) or that he is exempt lwrefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIX'ILRES D v U D
FZa Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
p t orcthan five hundred dollars($500).
I,asownerofthepropcny,ormycimploymswithwagesmtheirsolecompcnsedon, NEWRESIDENIUALELECTR _SQ,Fr. STORIES TYPECONSTRUCTION
anddmhewons Code:
no Contractor's
License
Law does
not apply to an Business
pm Professions CtWe:The Camramor's Lirense Lew does not apply tom owner of
property whebuildsorimpmvesthomon,andwhodmasuchwork h rofferor forroghhia
own employees,providedthet such improvememaarenm imendedornffend fmxda If. I OCC.GROUP RCS.UNITS
however,the building mimptommem is sold within one yearof completion,thoowmor- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owncroftbe progeny,am exclusivelycomracting with Hortiaedcomilicure to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
ommoct the project(See.7044,Business and Profusions Code:)The Cmtraoi
License Law docs not apply toanawnerofanTerty whobuildsorimproves thereon,and PERMIT ISSUANCE.
who contracts farsuch projects with acsnnracmr(e)licensed pursuant to the Contractors
Licm.Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this msson BACK FLOW I Ro r
TART Y_N
Owner Duro I RECEIM#
DRAINS-FLOOR, F, REA. 6Z)
x WORKMAN COMPENSATION DECLARATION C LTA, Y N
❑ Thereby nffvm that lhovearenificaw ofconsmnu ulLinsum,oraeeniEcete of FIXTURES-PERT RECEIPTp
Wormix'Compemntion Insurance ora sonified copy toamaf(Sov.38W,Lob C.)which �t KFEE Y N
tj
covers all employee's under this permit GAS-EASY TF.M-li .401TUARTS/ // - _ RECEIPT#
Policy# ) •J BUILDING DIVISION FEES
Company GAS-EA.S M-OVBR4(I?A) NCH CK FEE .7S_
❑ Certified copy is herchy famished.
❑ Ccnified copy is filed wiN Ne shy inspmdon division. GRPASE(INDUSTRI,WASTE INTI:RCEFIOR GRADING IRE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ITT -
COMPENSATION INSURANCE
(This section necid nm becomplewdifrhe permit isformehundrMdollues(SI00) SEWER-SANITARY-STORM EA.21on, ENERGY ITE
to loss.)
I sonify that in rhe performance of the work for which this permit is issued,l she] WATER HEATER W/VP.NT/ELECTR
not employ any person in any manner 10 as to became subject m the Worker% PAID
Compensation Lawaof Coliform.. Date WATER SYSTLM/IRFATING Dam Receipt#
O Z Applicant
Z 0 NOT ICE TO APPLICANT:If,after making this Cenificthe of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
pV] became subjecuo the Workds Compensatim provisions of the labor Code,you most
a ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE ^o0
LitQ CONSTRUCTION LENDING AGENCY SEISMIC FEE r
Z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.309],Co.CJ
Lks Leader'a Name PLUMBING FEE
Lender's Address that
QTY. MECHANICAL PERMIT' FEE,
V 1 unify thus I have read this application and more that the above information
ng is MECHANICAL FEE
4 cored loner to ctcom ly ndisca y city and county onlinatcasmtd cute lawsrelatingupon the PERMIT ISSUANCI?
building construction,undhcrcby emhorieerepmsenutives of this cirymemer upon the CONSTRUCTION TAX
U 7-. above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
linbilities,judgmenu,costs and expensesvhi h may Fn any wayaccmea,torto said City AIR HANDLING UNIT(TO 10.(100 C17M)
in can segs a of the ruming "his
p
19, 1AIR HANDLING UNIT(OVER IO,IXp CPM)
Sign are of App1icmVCono-ucm G Dow EXHAUST HOOD(W/DUCIT PAID
HAZARDOUS MATERIALS DISCLOSURE: HEATING UNIT(TO 100,000 BTU) Dow Receipt
Will the applicant or future building ucupant store or handle havardava material
On defined hythe Cupertino Municipal Code,Chapter 9,12,and the Health and Safety I ICATING UNIT(OVER TOO,”BTU) TOTAL: IrJb
Code,Section 25532(x)?A.
,a VENTILATION FAN(SINGLE RISID)
❑Yes Ai ISSUANCE DATE
BOILER.COMP(31IP OR I I#),(q0 BTU)
t\'ill thea ormarmunts as building by rho lusmBay ey .An ualityc six,Mitanghemit PAID
us air conmminmts m deMee by the Bay Area An Quality Management
Jiehin? BOILER-COMP(OVF.R 100,0110 BTU)
❑Yea )(No NEW RESIDENTIAL MECI1. SQ.FT, '7199
I have mad the breacdom materials requirements under Chapter 6.95 of the MAY
ColiSrmia Ilexhh&Safety Code,Section,25505,25533 and 25534. I understand that
ifthc building does not currently have a tenant,that it is my rexpomibility to notify the ,#s11-y Ur'VV>✓1_MIMU
occupant of the requirements which must be met prior to issuance of a Certificate of V
Occupancy. A
Owner oremhorized agent Date TOTAL: ISSUED BY: A