25874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOUI.I.-L U .AI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILBIN6 PH0)Efa'IUEN'1'It'ICA1ION 5 O
Jo l•�
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMIITALDATE
UNIT# LOT0 �
O ?RSNAME: PHONE: 'RACI'OR'SNAME: LICNO:
NIC CONTROLp
l I brvvwpJJVLIC NO: AD13S ❑
CONTACT: PHONE; QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
HOr -7-3 Y_ — NLDG I! PLUMB i9�!��
PERMIT ISSUANCE.
LICFNSEOCONTRACTORobsomiARATION APPLIANCES-RF.SIDENf1AL )O asses,
p a•Z Ihc¢hyvfRrnCENSE liCONT uACTORviaDECL RATE 9(commencing with
uF100 Section 7000)of Division 3 ofthe Business and Professions Cas.and my license is in PANELS
y WF. full force and effect.
FZW Lice- Cl C!2 Lic.p UPT02MAMN ,LiR
a Q a a Convector 301-I"AMPS
ZOrii ARCIIITCCTS DECLARATION OVER IMOD AMPS SQ.IT.FLOOR AREA E/SQ.FT.
I understand my plans shall b,used a public mounds.
Fy
W SIGNS ELECTRICAL
� �a Licensed Professional
G OWNER-BUILDIiR DECLARATION SPECIAL CIRCUIT/MISC.
OaF I hereby affirm that I em exempt from the Contractor's License Law for the ED e
'3km following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
H which requires a Permit to construct,star,improve,Jemnl ish,or repair any strveture
O p�
fN}� a its issuance,also requires the liesnt forsuch tat file a signed statement POWER DEVICES d `�
prior qui PP pcmti gn
C 00 that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
aao� 9(commencing with Section 7")mOvision 3 ufthe Business and Professions Code) SWIMMING POOL ELECTRICAL (IN Its
a'^y mthat he isexempttherefmmand the bnsisfor thealleged exemption.Anyviolationof
I_-Z¢ Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of OUTLETS-SWITCHES-FXTURFS
LSO not morcthen EvehundrcA dollen(5500). NEW RESIDENTIAL ELECIR _SQ.FT.
Chpce ❑ Laown<rofNeproPeny.ormycmployas withwegesathcirmlecompcnsation, TYPECONSTRUCTION
will do the work,and the structure is not intended or offered for sale(See.TOIL.Business
and Professions Code:The Contravenes License Law does not apply to an owner of
prnpeny who builds m improves thereon,and who des such work himself or through hie
oweemployeas,provided that such improvements an no iatendedoroffemd forsale.If, OCC.GROUP RES,ON]'1S
however,the building or improvement is sold within one yearofer mpledon,the
i owner-
f �_
budderwillhavemeburdenofprovn that hedid not build or improve forpurpose of
ulaJ.
❑ Luso ownanf the Property,am exclusively comructing with licensed contractonto QTY. PLUMBING PERMIT PGE Iq.00D LONE APN
unstrun the project(Sec.7094,Business and Professions Cale:)The Contractor's
License Lawdoesnotapply m an ownaofprepcny,whobuildsmimproves thereon,and PERMIT ISSUANCE
whocontmcts forsuch projects with a connotations)licensed pursuant rothe Convector's
License law. ALTER FA
) FEESUMMARY
❑ I um exempt under So. ,B&P C fm Iiia renin BACK FLOW PROTECT.DEVICE. SANITARY OUTSIDE FEES
Y N
Owner Doe RECEIPTp
DRAINS-FLOOR,ROOF, COND.
WORKMAN COMPENmofton DECLARATION SCIIOOLTAX Y N
❑
Workers
Co pffimna thatationI have
onal.ccateof conttnnreef(iee.380 .augh C.)atoofwhich FIXTURES-PER TRAP RECEIPI'p
Workers'Cmployee'iunlesunnceorscenificd copy thereof(Sec.3800,Lab CJ which PARK FF,E Y N
coven all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT
Policy p pUlIA1NG DIVISION FEES
Compnmy GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GREASEONDUSTRL WASTE,INTERCEPTOR GRADING FEB
CERTIFICATE OF EXEMITION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectionnadnmbecompletedifthe permit is foronehundreddallars(SIM) SEWER-SANITARY-STORM PA.300F1'. ENERGY FETE
or less.)
loarifythit inthe perfrsommeeofthe work for which this permit a,named,I shall WA1I7R BEATER WIVENT/ELECTR
.or employ any person in any mmmer m as In become subject a the Worker% PAID
Z Compentromnlawanf Califomia. Date WATER SYSTEMy1REATING Uma Roeiptp
Applicant
z� Q NOTICE TO APPLICANT:It,,oftee making this Certificate of Exemption,you should NEW RISIDCNTIAL PLMB. SQ.Ff. TOTAL:
!—I r/) become object to the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or th is permit shut]be deemed revoked. BUILDING 173E
w CONSTRUCTION LENDING AGENCY SEISMIC FE
5 z T!
I hereby affirm that there is a construction lending agency for the pertmmence of
V O the work for which this Permit is issued(Sec.307,Civ.C.) TOTAL: ELECTRIC FEE /p
Lender's Name O PLUMBING FEE� 4nder's AddressQTY. MECHANICAL PERMIT FEE
V I cenify that 1 have read this application and state that the above information is MECHANICAL FEE
correct. I Man to comply with all city mrd county ordinances and mate laws relining to PERMIT ISSUANCE
buildingaonxtrucdon,vtd hereby authodae rtprcsenativa of this city mcnaruponthe
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liebilitie,uJgnems,cosB ender nos hichmay inany way mcrveegeinst said City AIR HANDLING UNIT(TO IgalO CFM)
imam. ceufthe granting re it.F`
F AIR HANDLING UNIT(OVER 10,0W CFM)
'ign of Pllcmn/C este Date TXIIAUSTHOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,811)BTU) Data Receiptp
Will the applicant or future building occupant stare or handle hierarchies=room[ (BATING UNIT(OVER 100,0118 BTU) TOTAL:
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety nn
Coda,Soti d5532(a)1
11 Y55 ❑No
VENTILATION FAN(SINGLE REST[))
1 V
❑
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will IhI,amcuntorfas is deldin by he
Am.Air Quality
cManaghemit 11994
Dourio us air mmemiwns us defined by the Bay Arce nit Quality Managemtnl BOILER COMP(OVER IM,M0 BTM FEB
Diatrin?
❑Yes ❑No NEW RESIDENTIAL MEC I. SQ.F7, Qr I/Urtl'I I IIVQ
1 have mad the hamrdous materials 5a under 34.Chapter1 un erst of the CII Y
California a mad
Salary Carla,Sections25505,25533.1m rommand 25534. 1 undersand tont
it Ohe building docs not curently olives tenant,chat it is my responsibility w notify the
occupant(if the requirements which must be met prior to issuance of a Certificate of
Occupancy,
Owner m uwhori ed agent Das ISSUED BY:
OFFICE