25040 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUIL.to i- 'R- APERMIT NO. C //I'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 5 O T O
BUILDING PROJECT I DEN'PIFICATION
BUILDINGADDjES5: SANITARY NO. APPLICAHON SUBMITTAL DATE
2 �kIO UNITM r114l I OTM 2 C���3
OW ' SN PININE: CO A 1'OR'S NAME LIC NO:
- N/C CONTROL#
1 /
•AR IDT: /ENGINE LI NO: ADDRESS:Oil H, // ❑
W .
517
COM'ACI': PHONE: QTY. ELHCTRIC PER FEE BUILDING P�RMIT INFO
BLDG ELECT' P
\ I-U,yB MI;CI)
PERMIT ISSUANCE rlYIXJIt—. IA/uT`ItF'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RsSID TIAL. JOB DLSCRIVI']ON
mCZ I hereby affirm that l am licensed undeprovisionsof Chapter9(commenciagwilh
w 00 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS L
fell force and effect.
Licenas Class [.it.a HP'S l
y Dale Coatraanr 0 ( PS
FyZ ARCIIITECTS DECLARATION SQ.IT.FLOOR AREA MQ.IT.
ZOv—
I understand my pi...hall be used m public record. R AMPS
OZ—m
u1 SI S ELEOINC
Q
OWNER-BUILDER DECLARATION SPFJCIAILm,4 Licensed Professions]
C
Ca e
XOd I hereby affirm that I am exempt from the Contractor's License law to h<
ad to following reason.(Section 1031.5.Business and Professions Code:Any city a,county TEMP. OR INST.
V,-J which requires a pnmit to asmwq,sheq intprovm,demolish,or repair any swcwre
�tq}; prior 1p its issuance,a]'.rauires the applicant far such Permit to fileaxigned,comm, POWER D CES
1<0 that he is licensed pursuant to the provisions of the Contractor a License Law(Chapter
9(commencing ) SWIMMING POOL ELECTRIC
( gwith Section 1t100)ofDivisionJof the Business end Professions Code I� VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 27
I..ZQ Section 7031.5 by any applicant for a perant subjects the applicant a civil penahy of �ODO
ESm sol mare than five hundred dolWrs($5W). NEW RESIDENTIAL EL PRT
w~m EI1,asowoerofthe Mrop .ormyemploy swithwagessstheirsolccompcnsafion, f �f(yilESl TYPE CONSTRUCTION
a3— will Anthe work.and theswaurt is notimcndedaroffertd forvle(5«.1(144.Business \V� I
and Professions Code:The Contractors License Law does not apply to an owner of
properly whoboulds at improves themon.and whodoessucb work himsclfor through his ty
own employees.pmvideJ that such improvementsarmor imendclorofferd forsele.If, 1 'ROUP RES.UNfI'S
however,the building orimprovemem is said within one year of completion.theowner. ate.
builJer will have the burden of proving that he did net build or improve for puryou of J
sole.), QTY. PLUMBIN r ;RMIT 1•
❑ I,as ownecof the Property.umexclusively. contracting with licensed amuselomto .00D ZO 1? APN
onstrtct the project(Sec.1044,Business and Professions Code:)The Conuacmr's
LicenseUwdme%notapplytoanownerofpfopanywhobuildsorimpmvesthereon,nod PERMIT ISSUANCE
whucomracts forsuch pmjecu with acamemorfs)liccrued pursuant the Contractors
I isenss I avvALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I ran exenpt under Sec. B&P C for this mason BACK FLOW PROU ECT.DEVICE U'ISIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA,GOND. RECF.IPI'a
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherehy uffinn thmlhavcawnificae nfnmsanuo ulGinsurt,orucertificneofFl%TURES-PER TRAP RECEIP N
Wurkerti'Gsmpensmlun lnsumncc orecenlBeJ copy thereof(Sec.3g00,Lab CJ which PARK IL? Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'a
BUILDING DIVISION ZEES
Policy Of
Company GAS.EA.SYSTEM-OVER4 EA) PLANCHECK FEE O
❑ Cedifiedeapyiaherehymmimed.
❑ CenifeJ copy is filed with the city ivpection division. GREASRONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP.ASETRAP SOILS PER
COMPENSATION INSURANCE
This section need not he completed if the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEB
or less)
I ceniryannhn in he perfommsorr be work for which this furnal is issued.l shall WATER HEATER W/VFNT/ELECIR '7 ��
not employ y person to any manner so as to become subject to the Workers' PAID T_J r�7J
Compensation Lnwx^r Califumiu. Dune WATER SYSTLM/fREATING De Receipts
U 2 Applicant
ZC) NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RFSIDEN11'JAL PLMB. SQ.FT. TOTAL:
F" ^ ecosu
bme bject to rho Workerb
Workers Compensation provisions of the Labor Code,you mst
u
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE WW
aia
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iheeby affirm that them is a construction lending agency for the peformance of TO L: ELECTRIC IEE
the work for which this pc—it is issued(Sec.3097.Civ.C.)
U Lender's Name PLUMBING 17EE
u" FLender's Address QTY. MECI IANICAL PERMIT FEE
U I certify that 1 have read this application send stem tum the above Infoanmion is MECHANICAL FEE
>" LLl most. l agree to comply with all city and county committees;and state laws rclvingto PERMIT ISSUANCE
F-' 0" building construction.and hereby mallorice rtpesmnWdvesnfthis city to saner upon the
(� 2 above-mentioned property for Inspection purposes. AL TERORADDTOMECII. CONSTRUCTION TAX
TL,
(Wc)agree er save,indemnify anJ keep bamdess @e City of Cupertino against
limilities,judgmen¢.costs andexpenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,"CFM)
in consequence of the granting ser this permit.
AIN HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanUContructor Date EXI IAUST HOOD(WMUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(W 100,0011 BTU) Date Receipt#
Will the mpplieanl or furore building occupant atone of handle hazardous material TOT
as defined by the Cupcnino Municipal Ce Je,Chapter 9.12,and the Heahh and Safety HEATING UNIT(OVER 100.001)BTU)
Gude,Section]5532(x)? .NTILATION FAN(SINGLE RISID) Ill Jill
❑Ves )(Ni,14
'` BOILER-COMP LHP OR 110.000 BTU) ISSUA E ATE
Will the applicant or future building occupant use equipment or devices which emit
hamneus air cnmuminams as defined by the Boy Arca Air Quality Management BOILER-COMP(OVER 10BAM BTU) � ' D
Dinrial? o
❑Yes NEW RESIDENTIAL MECII. SQ.FT.
'dib!"have read the bmallous maensls requirements under Chapter 6.95 of the JUN 07 1993
n ,is Health&Salety Calc.Sections 25505,25533 and 25534. 1 mocomnd than
if the building does not currently have a tenant that it is my responsibility to notify the
occupant oft is ust be met prior to issuance of s Cerif she of C1 I Y V UrCPt 1114U
OccuM^ 1 a,
Ownerot or au Date l' ISSUED BY: LI
OF — -