25902 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
111ITINirF,LFZ1 A. PERMIT NO.
CITY OF CUPERTINO PLUMBING-MECHANICAL 25902_
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PRWE(71'IDEN'I'IFICATIUN
BUILDING ADDRESS/L� `c-t /� /] SANITARY NO, APPLICATION SUBMITTAL DAM-
UNIT
ATE
UNIT# �` O \ LOTN if 1' U
pPRONG:
CONTRACTOR NAAlME LIC NO:
(<I 46S '4 I0_ �nV//C{ N/C CONTROL#
TECTAiNGINF,ER: }.IC/O ADQR�S: 'i+ 0�6)gK^"` - ,^ El
ACT: - l/:_!PHONE: QTY. (4 ELECTRIC PF MIITa-: ((�'J FEE RUILDING PERMIT INFO
BLDG ELECT PLUMB ECH
PERMIT ISSUAN E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RSIDEN`H L
omz Ihsrebyuffnn Nat l an licensed un&rprovisionsof Chapter9(commencing with LOB DISCRIPTION
+100 Section 7")of Division 3m,hc Bunincss and PrOms,i ulna Code,andmylummicsin PA BL
CLL fu 11 force andcIfc I, sfP_ll `Z— P 200AMPS
<K License CF- �Z D Liu#
m?er Dam Contractor 01-1000 AMPS SQ.FT.FLUOR AREA E/SQ.IT.
OQ=� ARCHITECTS DECLARATION /^, OVER IM P
I undemtund my plenexhull be credits Publicmcools. �' 1. / SI NS i E RICAN
FNS Licensed Professional! ,{\ �� !
�Weue]< OWNIiR-BUILDER DECLARATION I I.CIRCUIT/MISC.
pXX'Oy V Ing real all(Se that nm exempt from the Contmmoh e:Any Luw fur the > n p If�
yl3LLN following reason(Seclion 9(IJLS,Business and Professions Qdc:Any city m e.a,y T' P.METER OR POLL",INS 1. ) M 1�
[— ¢ which requires a permit to construct,alter,improve,demolish,or repair any structure
W }7
pplicantf
prior to its issuance,also reclaims the aor such permiuo file.sigmdsatemem POWER DEVICES
WaO that he is licensed pursuant o the provisions of the Contractors License Law(Chapter Zfl
a .� y(commencing with Sectionplgl0)of Division 3 of the BusinesamW Professions Code) SWIMMING POOL ELECTRIC k -
m^ynudist he isexempt therefrom and Nebasiefortheallegedexcreption.Anyviolation of
kya Sectio.9031.5 by anyapplicanl fm.penni"abjects Ne applicant.civil pemltyof Ol1TLET5-SWITCHES-
FIXTURES
ESO not more than five hundred Jollas(SSW). NEW RESIDENTIALELECIRS FT.
zl_. ❑ Lasowncrof lheprnpeny,ormyeniployms with wagesastheir.solecompeneaiov, Q STOHIIS TYPE CONSTRUCTION
d3— will do the work,and the structure isnot intendedoroffered for sale(Sm.]044.Business
and Professions Code:The Conuzmors License law does not apply to an owner of
property whobuildsm improvestamon,and whodoessuch work himselforthroughhis
OCC.GROUP RFS.UNITS
ovinemploycers,Provided rhatsuch improvements are not intended uroffered for sale.IL
however,the builJingor improvement is sold within one yearnfcnmpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.)" QTY. PLUMBING PERMIT FEE FLOOD[ONE APN
❑ [,as wnerofthe property am exclusively contracting with licemcdcotemcpars to
License
the IF uction(See.91144,Business and Pin,fiesyw1msiors Code:)rop The Comon,an's
License lawduesnotapplymanowncrof property whobuildsor improvevhereon,and PERMIT ISSUANCE
whocoanmens for such projects with actennractot(s)licensed pursuant o the Contractors ALTER-DRAIN&VENT-WATERHIA) FEESUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this reasonBACK PLOW PHO"1'ECT.DEVICE SANITARY
FEES
SANI'T'ARY V N
Owner Date DRAINS-FLOOR,ROOF.AREA,COND, RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm tbmlM1uveacenilicote of crnsem to self-inrvre,ora cenificam n( FI%l'URFS-PER TRAP RECEIPTp
Workers Compensation insurance or a certified copy thermf(Sec.3800,Lab C.)which PARK ITE Y N
covers all employee's under this permit. GAS.EA.SYSTEM-1 INC.4 OUTLETS HI BUILDING UI"
Policy# DIVISION FEES
b
C mpeGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cny mulled copy is hereby fumishod.
Cornified copy is filed with the city inspection division. GRIASEfNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXCMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(Dtissection need ombecompldcd if Nc,ranit isformufachdreddo1lars($100) SEWER-SANITARY-STORM EA.200iel'. ENI2RGY FEE
or Icss.)
I verify that in he ofommnce ofthe work for which this permit is issued,Ishal WATER HEATER W/VENDELECTR
not employ any Person in any manner sen as to become subject to the Workers PAID
Course nsationlawsof Calilomia. Dune JAIRHANDLINGUNTF(TO10,"Cittd)
ATER SYSW.M/TREATING Date Rum,#
0 z Applicam
z0 NOTICE TO APPLICAYU If,after making this Cenificaeof Exemption,you shouldEW RESIDENTIAL FUME. SQ.FT. TOTAL:
PV] bccnmesubiest to he Worker',Compemaunn pmvisiota of he Labor Cade,you most.
04 7 fanhwilh comply with such provisionsnr this Permit shall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that is a construction lending agency for the Performance of
z TOTAL: ELECTRIC HE
U 0 the work for which thin Permit is issued(Sec.3f,97.Civ.C.)
Lender's Name PLUMBING FEE
r1' F 1<nders Address MECHANICAL PERMIT FEE
0 V 1 certify that I have mad this application and sate that Ne above information is MECHANICAL FEE
>4 12.1 correct. l agree to comply with all city and county ordinances and state laws relatingtaERMIT ISSUANCE
Nbuilding construction,and hereby authorize mpresentouses of this city to emerupon the CONS'TRUCI'10N TAX
V z also m mentioned propcny for inspection pur ors. LTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep humorless the City of Cupertino against
liubili's,judgments,crasamdex swhic oy,n any wayaccmeagainstsaid Cityquence he•untinofthisp it IR HANDLING UNIT(OVER ILON)CFM)
Si mme.fApplicanUCm DaeXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE EATING UNH'(TO 100,110)BTU) Dao Receipt#
Will the applicant orfuture building occupant store or handle harudous materialHFA TING UNIT(OVER 100,0010 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Cl apmr 9.12,and the Health and Safety
Calc,S«tion 25532(a)'! VENTILATION PAN(SINGLE RESID) sem_
❑Yes ❑No
ISSUANCE DA'I'h
Will theappliesainfutumbuildingoccupant useequipmentandevices whichemit BOILER-COMP(3HPOR 1W.000BTU)
It aeations aircontaminates as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW.000BTU)
Diav;d'i 6
❑Yes ❑No NEW RESIUENI'IAh MECH.—SQ,FT.
' 1 have rail the hmallous materials requirement under CbN nm 6.95 of the p
California l Icahn&Safety Code.Sections 2550.1,25533 and 25534. l understand that
if the building does not currently have atenant,that it is my responsibility to notify the 6 V '99
meet
occupant of the"mo which must be met prim 10 issuance of a Certificate of /x b 7#A -
Occupancy. 1 .101 C//I
Owneror utuhmicd agent Dom ISSUED BY: rfl
OFFICE