25616 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBU111,65Nf:-ECL^f•,i'KMAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25616
BUILDING PROJECT'IDENTIFIC,A'1']ON
BUILDING ADDRESS: �a�� SANITARY NO. APPLICATION SUBMITTAL DATE
'O w"0. UN IT LOI'p 16-e�
O ?RS NAME: PHONE?: CONTRACTOR'S NAME: LIC NO: G V
N/C COM'ROI.p
•ARII I'1' GIN iR: V L .� ADDRESS; ❑
So _
CONTACT: PHONE?;
�JJ ��W.ry Ql'Y. ELECTRIC PCRMIT PEE BUILDING PERMIT INFO
)2AA V 3 Wo" `G//.�' — PERMITISSUANCF: �. BLDG ELECT PLUMB MECII
I/.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL fOB ISCRIPI❑ION ❑
p92, Ihereby affirm[list l am licensed under provisions of Chapter9(commencing with
POO1�. Section 7")of Division 3 aflhe Business and Profemions Code,and my license is in PANELS
WUr,J full force and effect.
p¢-ZW License Class Lic.0 UPTO 2N)AMPS �Wsr r+v
.<0- Date Coolant 201-1000 AMPS
Z~Or=` e' ARCHITECTS DECLARATION OVER[ON)AMPS SQ.FF.FLUOR AREA S/gQ.PI'.
OZ�C l understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
LL y`WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
5q(Oc. I hereby uffiem that I am exempt from the Contractors License Taw for the
WBWti following reason.(Section 7031.5.Businearold Professions Cede:Any egnr county THMP.METF.RORPOLEINST
which requires a Permian construct,alter,improve.demolish.or repair any suuctam
>� prion,its issuance,also requims the applicant for such permit o file a signed statement POWER DEVICES
ul �� that be is licensed pursuant m the provisions of the Contractors Licensel.uw(Chapter
a e 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Cede) SWIMMING POOL ELECTRIC yp1 DA
_xy onha[he is exempt hetefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES- �1 �s
Sa Sect ion 70315 by any upplimin for a permit subjects the applicam mecivil penahy of FIXTURES
mFp C notmore than live hundred dollars($500). ♦ V
L5� ❑ LecoerefNepropeny,mayemployees with wagesostheirsolecoripsti
enson, NI?W RESIDENTIAL ELF:CfII _SQ.FT. as
wnSTORIES TYPE CONSTRUCTION
3 will do We wnrk,md thestmewre ixno[Intcndedoroffercd forsale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
properly whobuildscrimprovesthereor,snd whodoes such workhimselforthmugh his OCC,GROUP RES.UNITS
own employees,provided that such improvements are not inumdedorotfercd forsule.If,
how er,the buildingor improvement is sold withrtmayetrofcompletim,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,mownerofthepmpny,amexclusiveiyconteactingwi[Slicensedcontmemmm QTY. PLUMBINGPERMIT IEEE. FLOOD ZONE. APN
construct the project(Sec.7044,Business and Professions Code)The Contnctor'a PERMIT ISSUANCE
License,Law does not applytoanownerol'property wholumidsorimprovesihercon,and
whocomractsfur such projects with acontmctmOd hear d pursuant to Ne Contractors
License Law. ALTER-DRAIN&VENT-WATER(BA) FEE SUMMARY
❑ 1 am exempt under Seh. ,B&P C far this reason BACK FLOW PRQIECT.DEVICE OUT• F.ETUT
SANITARY YN_
Owner Date RECEIITp
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATIONDECIARATION SCHOOL TAX Y N
❑ Ihereby s'CmapfBmks.that Inoaveecm.certified cupment,
.f(insum,or L.b Cq)ate ofwhich FIX'1lIRFS PER.TRAP RECEIPI'p
covders'Cmployewianlnr this nreanifiedcnpylhercof(Sec.3g00,Lub CJ which — PARK FEE Y_N
rovers all emDlnyee's under this permit _ 1�wv 11 C4 RDIVISI N
Policy p 'l14'� BUILDING DIVISION FEES
Company AS-EA.SYSTEMM- V 4( ) PIANCHECK FEE
❑ Certified copy is hereby famished.
❑ CCnified copy is filed with the city inspection division. U S ? RC n' GRADING FEE
C17RTIFICATE OF EXEMPTION FROM WORKERS' I GR B SOILS FEE
COMPENSATION INSURANCE
(This section need not be c npamd if the permit is for one hundred dollsrs($I m) 71—
SEWER-SANT -ST' R EA.774. _ ENERGY FBI:
or Ia"q)
I certify that in the performance ofthe work for which this Permit is issued,Ishall WATER HEATER W/VENT/L'LECI'R
not employ any person in any manner so as to become subject to the Workers' PAID
Z Compensation Lawsof Culifomia. Dam WATER SYSTENOTREATING Date Receipt#
Applicant
�r�z�sy-t 0. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RI?SI DENTIAL PLMB. SQ.FT. TOTAL:
t' U) become subject m the Workers Compensation provisions of the Labor Cale,you must
forthwith comply with such provisions or this pemtil shall be deemed revoked. BUILDING FEE —
G �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihembyaffimr thanhem iso construction lcndia,in,mcy for the performance of
U the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEF. /—
Lenders Name
OV larders Add.. QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and state that the uNice information ie
correct.I ugrce to comply with all city and county ordinance and some laws misting to PERMIT ISSUANCE MECHANICAL FEE
�-s building construction,and hereby rmhorim representatives ofthis city to enter upon the
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECII. CONS'fRUCDON TAX
(We)epee m save,indemnify and Jump harmless the City of Cupar ino against
'litie.judgmems,costsw npenseswlt hmaymarrywayaceme ainn said City AIR HANDLING ON I'I-(TO 10,000 CPM)
o eyuence atthe gmmi of this permit.
AIR HANDLING UNIT(OVER IO,WO CFM)
tgnatum of ApplicanU ummcmr LF Data EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
We b,,bathe Cupertint or o
Mreicipal gh,Chapter
aral pemrc or handle hHalthand aterialSafety HEATING UNIT(OVER 100,00(BTU) TOTAL:
e defined by the Cupcnino Municipal Code,Chapmr 9.12,and the IleeRh and Safety
CtMe,Section 25532(a)R VENTILATION FAN(SINGLE.RES ID)
❑Yes �No
Will theapplicamor Future huildingoccupant ueeequipmemnNeviceswhichemit
BOILER-COMP(31 IF OR 10(),"BTU) ISSUANCE DATE
harardom air contrunimnts a defined by the Bay Area Air Quality Management
District[ BOILER-COMP(OVER IOO,IMIO BTU) pp pp
13 yes AN. NEW RFSIDFNTIALMECH. SQ,FT. 6s W I D
1 have read the hazmdous materials requimments under Chapter 6.95 of the
California Health&Safety Cale,Sections 25505.25533 and 25534. l understand that ®�T _ 1
i bw ing docs not cancer[ ve a tenant.that it is my responsibility m mify the ,
gtmad d the mgkfrearents hick must he met prior toissuanc^e o' aaCC i cmc of
+
Oc1u V V S s I
r
Owner or umhmiaed egM Data TOTAL: ISSUED BY:
OFFICE