25230 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO b17t1:61NirE1.EC'I'klZ'AI, PERMITNO. a„ ^ a� a� 0
APPLICATION/PERMIT PLUMBING-MECHANICAL '2 fJ' '2 3
IiUII,DINf.DIVISION 1 DING PROJECTIDEN'I'IPICATION
BUILDING ADDRESS SANITARY NO. APPLICA'I ION SUBMI FIAT,DATE
VA�u G.►sHitab� PARK
S UNIT# ZOJ52— LOT# G ��
g PHONE:, ONTRACr R'S NAME: LIC NO:
N/C CONI'ROLa
„�A CHTECUENGINF.EiR: LICNO: D v.S A_ry ❑
L �7�G
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG Ii1.ECf PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pceZ IherchyafFrmthat]mnlicemed underprovisionsof Chapter9(commencingwith JOB DESCRIPTION
P00 Section7WBof Division 3ofthe Business unit Pmftssiom Code,add my Iicenm is in PANELS
full force
,y' 4g9'ZL2 UPTO200AMPS
a Liccnsc mss Lic,# 1
vFj=y me Contmcmr�`h 201.11100 AMPS l
7[0NZ AR CI IRECPS DECI. ATION OVER IOf111AMPg SQ.FT.Il,00R AREA $/5Q.fl'.
O'Z—C I undcotanJ my Iansll'Tull be u m as publi"verards. rL
SIGNS ELECTRICAL
a $j Liccnsm Pmfesmonu
�,W< O NE t-BUII.DF.R DECLARATION SPECIAL CIRCUFDMISC.
KOaUI hereby offitm thm 1 am exempt from the Cnnlracmr's License Low for Ne
W 3 IL, following mason.(Section 703 IS.Business and Professions Code:Any city or county TEMP.MEIT;R OR POLE INST.
C�Oa which Requires n permit m conshuct.Whir,improve,demolish,or repair any stmctum
Mprior to its issuance,also requires flr applicant fur such Permit to file a signed statement POWER DEVICES
WWanp that he is licensed pursuant m the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC 1 t 'L
a ao�' 9(commencing with Sorliud]0(1()of Division 3 of the Businessicd pretrial...Code) p� pppnnn,,, VALUATION
W_,o or that he is exempttherefrom and the basis or the alleged exemption.Any violation of OUTLEfS-SWITCHES-FI% FS '
I_�Q Scction]U31.5 by enynpplicunt furapermit subjects the applicanuoacivil penally of 1... 1 l
not mem Chun five hundred dollars(S500)'C� NEW RISIUFJJTIAL ELECIR S .FT.p [II,asawneroftuepopony.orniyamploymswithwmgesmthelrsolecompmation, Q STORIESI TYPE CONSTRUCTION
pW,s� will do the wmk.nnddicarucmm is not imerdedorol'feed To,our(Sec. Business
and Professions Cmc:The Comraciors License Low dues not apply to an owner of
prepcny who builds rn improves Nerenn,and who dRws such work himself or through his
employms,providedthat such improvements are not mundednrofferm Initiate.If. If
OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearnfcmaide ion,the owner-
builder will have the burden of moving that he did not build or improve for purpose of
ole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ANN
❑ I.asownerofthe progeny,ano xclusivelycontracting with licensed commemrsm
omhact Nr Project(Ser.7044,Business and Profession,Code:)The Contractor's
License Law Jens not apply manowner ofpmpenywhobuildamimproveathemnn.and PERMIT ISSUANCE
who contracts forsuch projects wlthamummunds)licensed pursuant tothe Conunaor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason BACK ROW PROTECT.DEVICE O T.TUE 1'F. S
SANITARY Y N
Owner Date DRAINS- RECEIPT'#
. FLOOR.ROOF.AREA.COND.
WORKMAN COMPENSATION U[CLARA'1'ION SCHOOL TAX YN
❑
Thereby Whim tlist lhave
rance orli momencodsanmof(Sce.3A o.Lab C.)itta ofwhich PIXTURfS-PIiR TRAP RECEIPT#
WmaBe employee's under
or G.J copy Nnceq$eo.3NW,Lab C.)which PARK FEE Y N
covers all employee's unJcr this permit. GAS- RDVISION FEES'#
EA.SYSTEM-1 INC.4 OUTOUTLETSPolicy# I
BUILDING DIVISION
Company GAS-EA.SYSTEM-OVER 41EA) PLANCIIECK FEE
❑ Certified copy is hereby minimum.
❑ Certified copy is film with the city inspection division. GREASENNDUSI'RL WASTE INTERCEPTOR GRADING FILE
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASE'[RAP SOILS FEF,
COMPENSATION INSURANCE
(This sectionnceJ not be completed ifthe pnman is free hundred dollars 4100) SF.WER-SANITARY-STORM EA.200FF. ENERGY FEE
or less.)
I cmify for in the gcnornanceuf the work for whichthis permit is issued,Isha11 WATER HEATER W/VENT/ELECTR
not employ any p:rsun in any manner so as to beceoe subject m the Worker% PAID
Compensation Laws of Culifomm. Date WATER SYSTEM/FRPATING Dae Receipt
Q z Applicant
z0 NOTICE 1'DAPPLICANT:If.after making This Cenificme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
P M Wcnme subject 0 the Worker's Compensation provisions of(be Labor Cede.you must
forthwith comply with such pmvmmes or his pe.it shall be deemed Revekm. BUILDING LEG
Lq Q SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Z I hereby affimvhatthem is a construction lending agency for Ne perfomance of 'TOTAL: ELECTRIC FEE
U Qthe work for which his Fermi Tis issued(Sen.3097,Civ.C.)
LT. P Lender's Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
U I verify that I have mad this application and state that the move information is MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and state laws miming to PERMITISSUANCE
f" building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cogeninn against
Iiabilities,judgments.costsand expenses which may in any way ocerat Was dCity AIRHANDLINGUNIT(TO10.000CFM)
consequence of the anur,(But
II /-VS AIR HANDLING UNIT(OVER IO.IN)U CPM)
Sigramm of Applicafii4'. rite Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT'(TO 100,)00 BTU) Data R cip N
Will the applicant or Tulare building occupant slue or handle haeardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and The Health am Safety I MATING ON]P(OVER 100,000 BTU) T A
Chir,Section 25532(a)? VENTILATION PAN(SINGLE RESIU) ��
❑Yes ID N. ISSUANCE E
Willthcit,liermerfuwrchnilding occupumuse eyuipmemordeviceswhichemit BOILER-COMP(311P OR 100,000 BTU)
• harardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1(I)Of10BTU) P A 9 D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
1 hove mad the harmJous materials ox,mmems under Chapter 6.95 of the tdUN 91 1993
California Health&Safety Code,Sections 25505.25533 and 25334.1 unJrmt4 drum
if the building due nut cunemly hove a tenant.Na it Ls my responsibility to notify the /x
ccupont of Ile mquimmenes which must be met prior to issuance of a CmiGcate of CI I Y VI` l#Uf-Cn l IIYV
Occupancy. I
Owner or umhorizrd ngem Dor TOTAL ISSUED HY�