25885 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO PERM]FNO. r^
APPLICATION/PERMIT PLUMB NG-MECHANICAL 5 H H V
BUILDING.DIVISION BUILDING PROJECT]DENHFTCA'I[ON
UILDINNG1 ADDRESS: ��// � J''' /////IDC// SANITARY NO. APPLICATION III'AL DATE
/U Psil�/FC /'ice' UNITO IAT a' 22
OWNER AME:,/ _ ' / PHONE: CONfRACTO NAME: LIC NU:
"A/� 0 //� A ,3";69W- i eZ' rv/c CONfROI,x
ARCHITECUENGINEER: LIC NO: ADDRESS:
td ,0 /9
CONTACT: PHONE: ELECTRIC PERMIT FEE BUILDING PERMIT INFG
QTY.
BLDG ELECT PLUMB MI:CII
PERMIT ISSUANCE D ) El El
LICFNSIiD CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �
JOB DESCRIPTION
oa4y Ihereby uffirinhat l ani licensed underprovisions AChVer9(commthencingwi
V)00 Section 70(sho1 Of vision 3 mile Business[an�d/Pro'f/es�s1ions Code,and my license is in PANELS
full force and elfect. 7tZTA�G UP TO 200 AMPS L ` ��,�
ha„7 W nsc Clnsx laic,p
-1-� Conv 201-IOW AMPS
Fy Uuc ARCIIIIECPSDECLARATION OVER 1000 AMPS S O RA E/SUI'Il
Z O rn— l understand my plans shell bused m public records.
0 y F W SIGNS ELECTRICAL
Q j Licensed Professional PUTER
e, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. '1 11r
KO tL 1 hereby Afina but I inn exempt from the Contactors License Law for the \ f
W 3 a on following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP,METER OR POLE MST. \ f
F=�Q which requires a permit a coramel,alter,improve,demolish,or repair any euuaurt Is—
'=<0
in Journalists suance,elm requites Remits.,far such pemuuo file.signed statement POWER DEVICES
'z D O thin he is ho med pursuant to the provisions of the Contactors Lice Law(C'hapter SWIMMING POOL ELECTRIC
dXocd 9gommcncing with Section 710010)of Division 3 of the Business and Professions Code) VALUATION
WMtn .1 but he is exempt themfrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES � O�
,Z> Section 003 L5 by my applicant fm a permit subjects be applicant o a civil penalty of
fEaO not more thanfivchundred dollars($500). NEW RESIDENHALELECIR _SQ.FT. STO)p TYPECONSTRUMION
=F. ❑ I,asowncrofthepmpeny,ormycmploymswithwages Ocirmlecompensaum.
willdothework,andtheswctumisnotimcnd moffa fm We(Sec.7W,Businas
enJ Pmfnsitns Code:'Ifie Contractor's Li«use law docs not apply m m owner of '
pmpcny who builds or improves thereon,and who dots such work himselfor through his
on employees,provided thutsuch improvements srenotintendedor Uffbmd forsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one yeasofcnmpletion,the owner- 'rO'A
builder will havc the unmeant proving that he did not build or improve for purpose of
'ole')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lits owner nl'ihe pngeny,nor exohcsivdy umtrecting with liecnsedcontuctors nt
construct the project(Sac.](94,Business and professions Coda)The Contractor's
1 License Law does not apply to iso'wncrofpmpeny whobuildsor improves Erman,and PERMITISSUANCE
whocominns forsuch projects with a contmemo s)licensed pursuanuothe Centa<en's
License Law. ACfF.R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I ant exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE 3
SANITARY Y N
Owner Uum DRAINS-FLOOR,ROOF.AREA,COND. RECF.IPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
�❑ Thereby affirm theJ haveattniftcam of room.,mself-imurt.oramnificae of FIXTURES-PER TRAP RECEIPT,Y
Workeli Compensation Insurance ora certified copy dtermf(Sec.3800.LAC.)which PARK FEE Y N
RECEIPTM
covers all employzy/x ca,this Pconan. GAS-EA.SYSTEM-1 INC.4 OUTLETS �
Policy If OO BUILDING DIV ISI II:IS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ enifled copy is hereby furnished.
crinied copy is filed with the city impecuon division. OREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR BASE TRAP SOILS PEE
COMPENSATION INSURANCE
(Thisseedon need not b completed ifthe permit is Income hundred dollars($100) SEWER-SANITARY-STORM EA.20(1 ENERGY FEE
or less.)
Icmify that intbe performance of the work for which this permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any pe,o, to any matater so as to become subject to the Workers PAID
Compensation Lwsof CAifomia. Date WATER SYSTEM/IREATING Date Receipt#
O Z Applicant
z NOT ICE TO APPLICANT:Ir,after making this Cenificata of Exemption,you should NEW RESIDEND JAL PLMB. SQ.Fr. TOTAL:
I/I become subject o the Workers Compensation pmvesus of the Labor Code,you must
� forthwith with such provisions orchis pandit shall deemed revoked. BUILDING FEE
.>
1 [� CONSTRUCTION LENDING AGENCY SEISMIC EEE
Z) z Ihereby.M.Nat them is aconswetian lending agency for the performance of TOTAL: EL
FEE f
U O the work for which this pmorn is issued(Sec.3007,Civ.C.)
Icmdcrs Name PLUMBING FEE
D" F Lenders Address QTY. MECHANICAL PERMIT FEE
O U 1 certify that I have mad this application and sate that the above information is MECHANICAL FEE
correct. I time to comply with At City and county ordirunus and sure laws relating to PERMIT ISSUANCE
h building construction,and hereby suthodm repremnuuv<softhis city to enter upon the CONSTRUCTIONTAX
U z above-me.,ioned property far inspection purposes. ALTER OR ADD TO MECH.
(We)agree m Y=�=adulh
d keep humdess Ne City of Capron against
It. 1, menmmay in any way eccmengalmt said City AIR HANDLING UNIT(TO I0.000 CFM)
ce ORf this permit.
.n ten z 3
f AIR HANDLING UNIT(OVER 10,000 CPM)
n
Signatumpplicwucartarmr ate EXHAUST HOOD(W/DUCT) PAID
I IAZARDOUS MATERIALS DISCLOSURE If EATING UNIT(TO 100,000 BTU) Dae Receipt#
Will Ne apPllwnl or future building occupant store or handle hamrdous material HEATING UNIT(OVER 100.0(y)BTU) 7AI_
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ihand,and Safely
Code.Section 25532(a)PVI3N1'lLAT1ON PAN(SING LH RESID) -'��
1:1 Yes 1:1 No
ISSUANCE DATE
WIIl the applicant or futurebuildingoccupantuseequipmentordeviccs which emit BOILER-COMP(MIPORIW,WOBTU)
haeentons air commmion is as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU)
❑Yea Cl No NEW RESIDENTIAL MEC11. SQ.FT. V'
I have read the hazvdso s normal,requlmanams under Chapter 6.95 of he FEB
CAifomia Health& s 25
lately Code,Section505,25533 and 25334. 1 understand that a]
if the building does nm currently have a tenant,Nat it is my responsibility to notify the QJ 'OAn
occupnt aofill requirements which must b met prim to issuance of a Certificate of Ilk
vJ7
Occupancy. ELit
D
� Jr ,
Owner or amhomW age., Dam TOTAL: ISSUED BY P
OFFICE