25599 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO IBL�LRCPRMI• PE•RM]rNO.
APPLICATION/PERMIT rLUMmNG-MECRANICAI.
BUILDING DIVISION HIIIIAINC PRUdF(TIIIF;NTIFIf,AT10N 25599
BUILDING rsDOF.Sgy , V 1 _ U Ta LOTp SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'NA B: /fYV�9 '/PfLp/LNEj`':, ,w CONTR f R'S yAMB: LIC NO:
/*Vt �QIj e u v� T7?-��v ��i OCG(v" I�RSOrr 375 22( NIC coNTRO a
ARCII 'NGINEFR: LIC NO: ADDRESS:
�7yPsr7'leasaa2 f Vow AP•. .5,61 Ale ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE IV ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL L�
OcZ I hereby ufirn that l an licensed under provisions (commencing JOB DESCRIPTION
iW OOF Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
FQLU Lu`Icnr,Cmde(fecl.rzp Lica -774 17 UPT0200AMPS
to<y Dane C l Convautor 201.1000 AMPS
Z FOy2 ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR ARG SISQ.IT.
O Z I undersand my plana shall be used as public records.
roo SIGNS ELECTRICAL
<< Licensed Professional
C OWNER-BUILDER DECLARATION SPECIAL CIRCNryMISC.
NOyU I hereby affirm Nn am exempt exempt from the Commence,License law for the
31s-v~i following reason(Section 7031.5,Business and Professions Code:Any city oreounty TEMP.METER OR POLE INST.
L's v, which requires n permit to construct,alter,improve,demolish,or repair my structure
;!(T� printer,its issuance,also requires the applicant for such Permit o file asigned statement POWER DEVICES
ty.-<Oz that he is licensed pursuant to Ne provisions of the Contradols License Law(Chapter
a cLL 9(cnmerrem,with Section 7W)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATIO G•
f,y enlist heisexempthercournmd thebusisfodmidlegedexemptim.Any,k4minnof OUT •SWITCHES- L
tZY Section 9031.5 by my applicant for a permit subjects the applicant to a civil penalty of FIXTURES ` i�76
G t mare tout five hundred dollar(5500). NEW RESIDENTIAL ELEC It S .FT.
W n❑ .thea void the stracm.snot mended.rthwegesed rside( ee.cW,Buauon, -SQ.FT. TYPE CONSTRUCTION
2 .., will Jothcwok,Cordo:
The Comisnot is License
La doesr of apply I.an.Business
mJ Professions Code:The Convene',License Law does not apply tf an owner ofis
ownenywyeeslen ,pdsorlmprovesthimprovements an otihwidehraffiril through his OCC.GROUP RES.UNITS
hoemployees,provided that inch i mprov emems ate not intended m of&red for wle.If,
wever,the building or improvement is sold within one year ofcompletiun,the owner.
hi ildcr oil I have the burden of proving that he did not build or improve for purpose of TOTAL:
le.).
❑ 1.asownerofthepmo y,amexclusivelycmmoingwiNli"e mnmcmrvm QTY. PLUMBING PERMIT FEE ILOODZONF. - APN
construct the pmject(Sec.Wive,Business and Professions Code:)The Contractors
License Law does notapply tomowncrefiampeny whobefics or impoevesteceson,and PERMIT ISSUANCE
m
who contracts for such projects with aconmetods)licensed pursut to Necmeo are Al11ER-DRAIN&VpNT-WATIeR(G)
License law. ITE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reason BACK(LOW PROTECT.DEVICE. ID. T7S
N Y Y-s N
Owner Data DRAINS-FLOOR,BOOP,ARG,CO I RECHIPI'p
WORKMAN COMPENSATION DECLARATION H TA Y1 N
• ❑ (hereby affirm that l have a certificate ofeensem to sel Ginsure,or a certificate of p �.. RECHIPTY
Workers'Com FIXTURES-PER TRAP
Compensation lnsumnceoraanif¢d copy tl¢rcof(See.3800.Lab C.)which 41�11NEOE Y: N_
coven all employee's under this pennie. GAS-G.SYSTEM-1 INC OOVI'LETS ." RECEIPT#
Policy ILDING IVISIONFEES
Company GAS-G.SYSTEM-OVER 4( )
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division. GREASHANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OFEXEMPTION FROM WORKERS' GRHASETRAP SOILS FEE
COMPENSATION INSURANCE
(TWssection remain becomple al ifthe permit is forme hmdrecdollen($IN) SEWER-SANITARY-STORM EA.200FT. ENERGY FtiE
re In..)
I cenify that in the performance of the work for which this permit is issued,)shell WATER HEATER W/VENT/ELECfR
not employ any Person in my manner so as to become subject to the Workers' PAID
Cnmpareatim Lawsof Califamia Data WATERSYSTEM/BGTING Date Receipts
Q z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR SQ.IT. TOTAL:
become subject to the Workers Compensation provisions fthe Labor Code,you most
�i forthwith comply with such provisions or this mantshall be dammed mvoked. BUILDING FEE
a [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm thauhcre is a construction lending agency for the performance of TOTAL: ELECTRIC HE
the work for which this permit is issued(Sec.309'!,Civ.C.)
lender's Name
OF Lender's Addreaa QTY, MECI IANICAL PERMIT' ITE PLUMBING FEE
V 1 cerity that I have mad this application and suite that the above information is
L>a correct I agree to comply with all city and county ordinances and state laws meting to PERMIT ISSUANCE MECHANICAL FEE
building construction,and lecreby authadse mpneemadvo of doicity..ratm.pco the
U above-mentioned property,for inspection purposes. ALT ER OR ADD TO MECI I. CONSTRUCTION TAX
(We)99gree I save.indemnify and keep hernless the City of Cupenino against
liabilities'LJgmenb,<osui mdexpcnaeswhichm nmywayaccru'agaimtseid Cit AIR HANDLING UNIT G O 10,01%1 CPM)
m co sy�R�;Y,/e or do, 7,
ag of'�rtn/�� AIN HANDLING UNIT(OVER IO.INIO CFM)
Si uncof Appl nnUCommn Date EXHAUST HOOD(WNUC7)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Dote Receipt#
W ill the appliamt or future building occupant store or handle haaa dom mnerial
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER ID0,000 BTU) L
Cole,Section 25532(a)? VENTILATION FAN(SINGLE RF.SLD)
❑Yes ❑No
Will the epplicantorfuturcbuildingoccupmt mcequipmem or Devices whichemit
BOILER-COM('(311P OR 100,000 BTU) ISSUANCE DATE
harallom air conamirmlts as defined by the Be,Ates Air Quality Managcmem N% gV.�
� BOILL'R-COMP(OVER 100.000 RTU)
District? m A
C3 Yes ❑No NEW RESIDENTIAL MECH. SQ.FL P
I have read the haurdous materials requirements under Chapter 6.95 of the S� 301993
California Health&Safety Catm tle,Smum.
25505,25533 and 25534.1 understand toss Mb
if the building does ncurrently have a tum,thin it is my responsibility to notify the
occupant of the requirements which must be met Prior to issuance of o Certificate mf - s u+
Occupancy. L1lr ser v
Owner m outhorircd agent Date TOTAL: ISSUED BY:
OFFICE