25067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nU-11—f7=E1:R,C FIR . PHRMIT NO. COC 7
APPLICATION/PERMIT PLUMBING.-MECHANICAL J U 1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL.DATE
UNIT# LOT# 7_`4rM
OWNyiRS AME.: HONE: CONTRA ME: � � C11F 4i►��, NIC CONJJJI'ROL•••#/
IVF ��G���q 2_ I
ARCIIIT[CI'/ENGINET:R: LIC NO: \ Ars:
`CONI'ACI': PHONE: BUILDING PERMIT INFO
Q Y. ELECTRIC PERMIT FEE
_ BLDG ELECT PLUMB MECH
PERMIT ISSUANCE , I E 0
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑p.Z Ihereby affrmtha l am licensed underprovisions ofChepter9 hommencingwith /N /I�
00 Sediun 90!118of Division]of theBucinepeuy s(ade,pyyptylrsnxe is in PANELS 'Fs ¢�� /V
z force and dfcat. ILJ1N VlN-�]` 1/A/V�/\ I
Qj 'rouse Class LI[.N UPTO2MAMM
vt-i<o- Date Conlr'uclpr 201-1000 AMPS
OR ARCHf1T:CTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.IH'.
Z m" 1 understand my plans shall bo used as public records.
Fy W SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIALCIRCUMIMISC.
KOyU I hereby allow that 1 am exempt from the Cannot, s License Law for the
W 3 a y following reason.(Section 7031.5.Business and Professions Code:Any city of county TEMP.METER OR POLE INST.
t Eb which requires a permit to consvua,iter,improve,demolish,m repair any someone
��}5. priurmim issuance.also rcquims the applicant for such permiuo fleesigned smec POWER DEVICES
in�C That he is licensed pursuant to the Provision.wfthe Contractor's License Low(CSWIMMING POOL ELECTRIC
ecd 9(commeming with Section 7000)of Division J ofthe Business and Professions Code) V ATIO I
ywj_y mlhatheisexempttherefromandthebasisfortheallegedexemption.Anyviolationof OUTLETS-SWITCHES-MIXTURES M P UTE R
F ]
Z GSection 7031.5 by any applicant for n permit suhjecm the applicant m a civil pemhy of
not more than five hundred dollars($500).
❑ NEW RESIDEMfIALELECTR _SQ.FT. 1{Ip' TYPE CONSTRUCTION
a_� ❑ oche w�k andtheropeny,ormyempendedarrofned forstheirso.704,L Usines, TE I
3— will Jothework,ande: Do,Coaisnotinnndese Law does ale(Stt to
of
and 1'mfnsiobu builds
pr Convector's License law uch at apply m an owatt is
proixny who builds or improves thereun,and who d«such work himxlfor through his
I dedthatsuchim t t' t ddnroffercJ for sale.If, OCC.GROUP RES.UNITS
crop thees,provi provemwithinne mese
however.the building ordeneflermntissold e did not yell or improefin,thaowner- TO
huilJer will have the burden of proving that he did not build or improve for puryox of
xxle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE Ar,
❑ Lasownerof the progenm
y,oeaclusivelycnntraming withrocrsmrsm
edcorano
omvaa the project(Sec.70,4,Business and Professions Code:)The Ccousemr's
License Law tl«s not apply man ownere propery whobuilds or improvestheseon,end PERMIT ISSUANCE
whoco micas for such projects with acanvanor(s)licensed punaam to the Contractor's
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. .H&P C for this rtawn BACK FLOW PROTECT.DEVICE SLUE 19ii35
SANITARY YN
Owner Dare DRAINS-FLOOR.ROOF,AREA,COND. RECEIFF#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
10 ❑ Thereby slfirm lhwlhuvc ucmifcme ofumunno self-in sur e,cruceirdkowof FIXTURES-PER TRAPRECEIPT'#
Workers'Compensation broamenceora«nifiedespy thereof(See.3800.Lab C.)which PARK FEE Y N
covers all cmpinyeox under this perm,. GAS-EA.SYSTEM-I INC.4 OUTLETS RDIVISI p
policy# BUILDING DIVISION PERS
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenilied copy is riled with the city inspection division. GREASFONDUSTRL WAST£INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PER,
COMPENSATION INSURANCE
(Thissechonneed not Fe camplemd if Ne permit is for one hundrddo11ars(S100) SEWER-SANITARY-STORM EA.20017. IhNERGYFEE
or Ices.)
I certify that in the perwaraoceafthe work for which thisprnnit isissued,ishall WATER HPATER WNENT/ELECTR
not employ any person in any manner so as m become subject m the Workers' PAID
Compensation Lawsof Califomic Date WATER SYSTEM/ffU,VBNG Dam Receipt#
O z Applicant
z C, NOTICE TO APPLICANT:If.afe,wou ng this CeAfieamaf Exemption,you should NEW RESIDENTIAL PLMIL SQ.FF 1'CIAL:
!n Ircarme xubject to the Worker's Compensation provisions of the Labor Cade.you must
� ? forthwith comply with such provisions in this pemdt shall be d«med revoked. BUILDING IFF.
1 [] CONSTRUCTION LENDING AGENCY I SEISMIC FEE
Z I hereby affirm that then is a construction lending agency for the performance of TOTAL: ELECTRIC FEE r
U O the work far which this permit is issued(Sec.YN7,Ci,C.)
I3. Icodcts Name TY. MECHANICAL PERMIT FEE PLUMBING WE
t-' Lender's Address Q
C U I certify that 1 have read this application and stem that the above infonnauan is MECHANICAL FEE
Y' LL7 correct
lagrecmenmPly with ell city and county oNievemes and stem laws refuting to PERMIT ISSUANCE
F' � buildingeonswaction.and hereby anchorite,representatives afthis city memer upon the CONSTRUCTION TAX
ie
U z above-me timed property for inspection purposes. ALTERORADDTOMECH.
Ove)agree to save,indemnify and kap harmless the City of Cupertino against
rahilits.El gom costs and expenses hichmayln ywayacemengma,aid City AIR HANDLING UNIT(TO IQ000CFM)
in conscquen eg It of t mut.
AIR HANDLING UNIT(OVER 10,000 CFM)
�G
Si( rev fApplicanVConramor Dam EXHAUST HOOOIW/DUCI') PAID
17
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.Oo0 BTU) Date Reecipt#
Will the applicant or faun,building occupant store or handle havadous material HEATING UNIT(OVER 100.000 BTU) TOTAL
as defined by the Cupertino Municipal Cade,Ceder 9.12,and[be Herb,and Safety
Code.Section 25532(u)7 VENTILATION FAN(SINGLE RISID)
❑Yes ❑No
BOILER-COME QHPOR W.000 BTU) 1$$ AIyGE A
Will airhe acumbirrimaw lure building by the Bay Ares Air Qwriv,Management
hu'rarJnus air rnmuminanta as def neJ by the Bay Arta Air Quality Mnnugemenr µOILER-COMP(OVIiR IfX1,000BTU)
District? MAY 131993
❑Ycs ❑No NEW RESIDENTIAL MECFl. SQ.FT.
JLbuilding
read the hazardous materials requirements under Chapter 6.95 of the 611 Y Ur GUrtnIIIYU
alth&Safety Code.Sections 25505,25533 and 25534.I understand that
g J«snm curcmly hamumnunl.that it is my responsibiliy to notify the the requirements which must Ire met prior to issuance nl'a Cenifisme ofhorized egem Dam I TO FAL: ISSUED BY: