25815 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUI:DIN:-RLELTRTCA. PERMIT NO. 25815
CITY OF CUPERTINO PLUMBING.MECHANICAL.
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECT IDRN'I'IF'ICA'I'ION
BUILDING ADDRESS: /' SANITARYNO. APPLICATI�ONSUBMITTALDATE
ZtA ( d E UNIT, LOT# 12—L 3
O S HONE: CONTRACT 'S NAME: ^ S LIC N N/C CONTROL#
• AR IIITF. I' IN+ER LICNO: RES ' 10aJ( ��SC - T ex
\�
Irl
Co TACI: PHONE' QTY. ELECTRIC PERMIT FEE BLDG BUILDING PERMIT INFO
PERMITISSUANCE �� ELECT P' MECI
LICENSED CONTRACTOR'S ECLARAfION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QCZ Ihereby affirm that l son licensed under pmvisiomm'ChaMer9(commencing with
LL00 Section 7000)of Division 341h,Business and Pmf..tons Code,and my license is in PANELS
Fg-W t full force and effect. UP T0300AMPS
fZcu I.ianu Class Lm.is
w Q N Date Contracwr 301-1000 AMPS SQ.FT.FLOOR AREA $ISQ.IT.
FyZ ARCHITECTS DECLARATION OVER IBBB AMPS
Z O m— 1 understand my plans shall be used as public records. LED IN
�y(_y�j SIGNS ELECTRICAL I /�s
QWma licensed Professinnnl OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. + n n I� �j p�
Cd
ow,U I hereby affirm that 1 ren exempt from Ne Contractnls License law for the V J u— U tl .R
W il:a y following mason.(Section 7031.5.Business and Professions Code:Any city orcounty 7RMP.METER OR POUF INST.
0.Q.1 which requires a permit to construct,aloe,improve,demolish,or repair any anowum
prior to its issuance,also noires the applicant for such pem+iuo rile a signed statement POWER DEVICES
K K uau
Q that he is licensed forswear the provisions of the Contractors License Law(Chater
p
dao 9(commencing with Section 70)0)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATIO
with.,he is emoold homfinan mtdfm husis for Nealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES /As/4
FZ_Y Section 7031.5 by any applicant for a permit subjects the applicemb.a civil pcndty of {lJylco
m more than five hundred dollars(1500).
�SSSSp NEW RESIDFJ4'fIAL FlECTIt _SQ.FT. STORIESTYPE CONSTRUCTION
C m n❑ lahowrk,,thepstruct.ormyemtendedwith wedforalei(Sec.cW.Buniess
ua will dothewons and Nc he Comure ustmtion imm�iouseLwdo for aply.044,Business
atW Professions Code:The Comremo/s License law does not apply lf an owner of
property
mpl.y.uildsorimproves Hereon.and whodmssuch workhimulforthroughhia OCC.GROUP KCS.UNITS
employees,provided thus such improvements are mon intended or offered for sale.If,
huilder ,will
building burden
of pme+n is hath within one year ofcomolve for the owner- T
builder will M1ave the burden of proving That he did trot build or improve for purpose of
sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I.as ownerof the property,am exclusively contracting with licensed contractors to
construct the project(Sec.70OL Business and Professions Code:)The CoatrwhisixPERMITISSUANCE
Licanw Law dess um apply to an owner of pmpe ny who bui lds ar improve thereon,end
whoeoenmmh fn...el projects with,commensis)licensed put to
the Con.10rI ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
(j Ism exempt under Stt. .B&P C for this reason T'SIDE PEES
BACK ROW PROTECT.DEVICE
SANITARY Y N
RECEIPfp
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
❑ Ihembyaffiren then l have aceniricete of conxnuo ulGimme,macemficaa of FIXTURES
EI TRAP RECIJI'I'p
Workers'Compensation Insurance or acanifed copy th=fjf Sec.380,Lab C.)which PARK FEF: Y—N
—
Workers'
employee's under this permit GAS-G.SYSTEM-1 INC. OLITLF l RECf;IPTp
BUILDING DIVISION PEI
Policy a
Company GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ceniried ropy is heresy,famish#.
❑ Ceniried copy is filed with Ne city inspection division. GRNASF/INDUSTRL WASTE INTERCEPTOR GRADING IyiE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
flTissection mednm be completed if Ne permit is force.hundred dollms(1100) SEWER-SANITARY-STORM EA.2001if. ENERGY FEE
orless.)
I certify ohm in the performance of the work for which Nia pennitis issued,Ihhall WATER HEATER W/VENT/ELECfR
not employ any person in any monnow so as m hecome subject to the WorkersPAID
Compenaanionlawsof Califwim. Dare WATER SYSTVMOREATING Date Reed#
O Z ppplicono NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z 0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should
F-' 0 becomesubpvtto the Workers Compensation provisions of the(abor Code,you must BUILDING FEE
>
forthwith comply with such Provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z 1 hereby affirm Nm Vert is a construction lending agency for Ne performance of OTA ELECTRIC FEE Z
U O the work for which this permit is issued(Sec.3097,Civ.C.)
lender.,,Name PLUMBING FEEILA
Q" F Lender's address QTY. MECHANICAL PERMIT FEE --ii
I certify that I have read this application and shote Nat the above information is MECHANICAL FEE
correct.I agree to comply with all city said county ordinances and state laws relating to PERMITISSUANCE
F-' buildingco st t n,and hereby authorize representatives of this city to tatter upon the / CONSTRUCTION TAX
U Z above. e^)
mal property for inspection puryses.
ALTER OR ADD TO MECH.
( e/ lom to save,indemnify and keep harmless the City of Cupertino against
Iiabilin .j ms.cosho and expenuswM1ichmayinanywuyao.m.,' sbaid City AIR HANDLING UNIT(TO IO,OW CFM)
in cons a I'ems-e�an(i sya 1
J n AIR HANDLING UNIT(OVER 10,000CFM)
,rear of Applican4Cantractor Date EXHAUST FOOD OXMUCD PAID is
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dale R 'p
1,01
Willihe applicant or future building occupant score or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TO
as d.r ed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)' VENTILATION FAN(SINGLE.RESID)
❑Yes ❑No ISSUANCE DATE
Will the applicant or future buildingoccupam mmeyuipn+entnrdevi<eswhichemit BOILER-COME QHP OR IWAX)RTU)
himi does air contaminants as defined by the Bay Area Air Quiliry Mmagetrmnt BOILER-COMP(OVER 100!100 BTI) A
District?
❑Yus ❑No NEW RESIDENTIAL MECE. SQ.FT.
1 have mad the hazardous materials requirements under Chapter 6.95 of the DEC 1 7 1993
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand Nan
if the building doe.,non currently have a tenant(hat it is try responsibility to mely the
cupmt of the reyuircment which must be met poor m issuance of a Cenifiate of QU V t Jr Cfi I ITVI
Occupancy. C �a�a�Q/
Owner or authorized agent Date '1)1 ISSUED BY:
OFFICE