25069 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILO;Nc-Rre' PERMITS°' 25069 L+(]
IsLUMBN';.MECHANICAL UJ
BUILDING
DIVISION APPLICATION/PERMIT BUILDING PROJECT'IUEN'1'IFICA'1'ION'
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL.DATE
10 [-n, W c w �
UNITS LOTp
OWN R\-NAM Pi}pMl�^. CONTR CNO: N/C COMBOhp
ARCHITECT/lINGINEER: LIC NO: ADDRESS: ul O� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LIC12NSED CONT'RAM OR:S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Dy.Z I hembyaffirathan l oro licensed under provisioroofChapter9(commencingwiN r ^— y
�0u�0 Seelion700(1 Division 3 of,he Busineas.nd Professions Code,and my license is in PANELS '\/\��� aflza ,31-•`
Toll fora and cffat. UP TO 2M AMPS N
a'L 41
Lk hies p
N Q% Do Contract., 201-1000 AMPS
F D Z ARCHIIF.CTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
'LOvt—
1 dersmndmyplun"bLhe used aspublicrecord,. QYER IOOOAMPS
OG—C
Pin Ful SIGNS ELECTRICAL
Licensed Professional
S ys a'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUTVMISC.
1 hereby affirm that 1 am c.ento from IM1e Conlraclaro License Law for the
m 3 m y following reason.(Section 7031.5.Business and Professions Cade:Any city encounty TEMP.METER OR POLE INST.
F LL 0 Q which ml dree a permit to c.Rawcn,alter,improve,demolish,or repair any structure
F;;(Y� prior m its issuance,also reamuss the applicant such parrot to file.signed statement POWER DEVICES r
Rmtheislicensedpumm�llotheprnvisionsofthe Contrucmr's License Law(Chapmr
Q
' SWIMMING POOL ELE
En
9(mmmcncing with Scotian JU00)of Division Jofine Business and Professions Code) VALUATION
ty—y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
~�G Sen ion 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OVfLETS-SWRCHPS-
F
�Sp not more than five hundred dollars(S5W).
YNEW RESIDENTIAL ELE STORKS TYPE CONS'IHUCITON
F-o [Ias
I, awnerofthepropeny.ormyemploywswiNw goo[Mirsolecampet 6th.
y3O2 will dame work,and the suucture is not for sele(Sm.7044,Business
and Professions Code:The Contractor's License Law dams not apply to an owner of DATE
property who mildsorimpmves lhemon,and whodens such work M1imxlforthroughhis
If, OCG FS
GROUP R .UNITS
employes,provide thmsuchimprovemenns amnotimm�edarof&red for We.
however,the building or improvement is sold within one yearofcompletion,meowner- TO'PAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale')'
❑ Lw
azonerofthe property,acontractingy, exclusivelcontractingn.
ng with licensed conraenm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmjmt(Sec.7044,Business and Professions Code:)The Columbus
License Law docs not apply loan ownerofproperly who builds or improves dimmom,and PERMIT ISSUANCE
whit contracts for such prejects with aconaactods)licensed pursuanuo the Connarm's ALTER-DRAIN&VFM-WATERD
License Law. ('E ) FEE SUMMARY
❑ I am exempt under Sea ,B&PC for this reason 001SIDP Flit,
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data RECEIPT If
c DRAINS-FLOOR.ROOF.AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ IM1ercby.ffrmthmih...rem rem.mention!
e,dee .f(Snaum,a as C.)which PUT URES-PERTRAP RECEIPfp
Wnrkcrs'Compcnsalinn lnsumncc aracmiged cnpY therenf(Sec.JSW,Lab C.J which PARK ItiE YN
—N—
covers all employee's under this permit. GAS-EA.SYSTEM INC.4 OUTLETS RECEIPT 8
Policy g BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Certified copy is hereby furnished.
❑ Certified ropy is filed with the city inspmGon division. GREASCANDUSTR,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR17ASETRAP SOILS ITHE
COMPENSATION INSURANCE
(TTds section eeed not becompldedHthe permit is for one hundrddollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les")
I certify that in the performance oflhe work for which this permit is issued.)shall WATER MEATIER WNEN'1'7CLECI'R
not employ my person in any anamince so as to become subject to Ila, Workers' PAID
Con,ameation Lawsaf California. Dim WATER SYSTEM/TREATING Date Receipt It
O Z Applicant
Z 0 NO]CH TO APPLICANT:If,after making this Certificate of Exemption,youshnuld NEW RESIDENTIAL PLM B. SQ.FT. TOTAL:
E"' y become subjmt to the Worker's Compensation provisions of the Labor Code.You must
> forthwith comply with such provisions in pean
this ut shrooked.ill be deemed BUILDING FEE
0.W Q SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm mid hem is a construction lending agency for the Rdifomtance of
U Q the work for which this permit is issued(Sm.7097,Civ.C.) TOTAL: ELECTRIC FEE
enders Name
Isnd
[2a t IPY. MECHANICAL PERMI'P FEE PLUMBING FEE
c Address
Q U certify mel 1 have read this application and stem that minformation above infatanion is Q
comm.I agree to comply with all city"county ordinances and state laws mining R PERMIT ISSUANCE n MECHANICAL FET:
F' building construction,and hereby uwhoriae mpresentafives Ofmisciry to enter upon the CONSTRUCf1ON'fAX
U 7. above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep harmless has City of Cupertino against
li.bilitics,judgm nu, coo it iswhich may in any way mane against mid City AIR HANDLING UNIT(TO 1 O000 CFM)
in quenc egmnlingo is wait.
AIR HANDLING UNIT(OVER IOAW CFM)
Sfnldm of Ar i.micuntmcmr Dam b EXHAUSTHOODOVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,IKID BTU) Dam Rcecipt 0
Will the applicant in future building occupant store at handle memento material TOTAL:
as defined by the Cuperino Municipal CMe.Chapter 9.12,and me l health and Safety HEATING UNIT(OVER 100.000 BLV)
Calc,Section 25532(a)7 VENTILATION FAN(SING REMD) ra
El El NO
ISSUANLE A c
Will them licanlorfumrehuilJin acct Luse enlmdevices whinc�mi, BOILER-COMP(3HPOR 100.000BTU)
IP s ran Area A qqq
harardnus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1 W,IXp NTD)
District? V"j n
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the 1� tar UUr tT1111`/XJ
California Health&Safety Cod34
Coale,Sections 25505,25533 and 255 . I understand mm
1
if IM1e building docs not cumenlly have a Rican,than it is my responsibility to mody me
oc,n,m.)'the requimmemo which mist be in,,pear m I.asuanee of a Cenif,am of
Occupancy.
Owner or.uthoriacd agent Dam ISSUED BY: