25970 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUICB;rx1i- .ECI BI11, PERMITNO.
APPLICATION/PERMIT PLUMBING-.MECHANICAL 25970
BUILDING DIVISION BUILDING PROJECT IIIEN nFICA•TION
BUILDING ADDRit ODS D BI�1-/ SANITARY NO. APPLICATION SUBMITTAL DATH
UNIT0 LOT# /, q 1
OWNERS NAM : PHONE: CONI RACTOR:S NAME: LIC NO'. NIC COM ROLA
�� Ai 37937E
RC1 'IECT ' GINEER:� LIC NO: ADD ESS: C s El
OMACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE El 1:1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Y' JOB DISCRI ON
py:z, I hereby affirm that l am licensed under provisionsof0apmr9(commencing with �.p
FcO2 Section 9000)nf Divium Sof me Businessand Professions (�Code,unit my license is in PANELS /(Isle, TOO* —'• �/�
y.V full force and-ff Llc M q e '7��— UP TO 20MI AMPS
Fly Licens lazs (9p(-r1Z-' J i- 1
HQd Uma Contractor 201-IOBOAMPS
SQ.Fr.FLOOR AREA ESQ.I.T.
'GOyz' RCFlITECI'S UECLARA'I'ION OVER 1000 AMPS
O Z—❑ I understand my plans shall be used as public records. kL ED "'
p
F„y�w SIGNS ELECTRICAL
S 7, Licensed Pml ®Vfewwro
�yd'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O pW,O 1 hereby afllrn Thal 1 am exempt from the Connector's Limn Law the 1
m L',0 i which
following quire%a. cern to construct,
t,ainessanr improve,
moll Code:Any city "them county TEMP.MISTER OR POLE INST.
�W J which its sires a permit reconstruct,applilic,cant
improve,dPermit or repair any snunure
f.�Yto its iawance.elm the licant for such Permit dsurement POWER DEVICES
prior requires OP a 6La
iS�� 9(coni that he imucen with
Parsmam Section ")ofDthe ivisionns the Cc Brains License scimax ode) SWIMMING POOL ELECTRIC I
C 9t that
henexempt therefrom
the Division 3o(the Business and Professions Code) ` VALUATIO
GXU❑y or he is exempt end the basis for the alleged exemption.Any violation of
OUTLETS-SWITCHES-FIXTURES
F Z Q Section than by any applicant fm a permit subjecu the applir t m a civil pcnahy of /
F NEW RESIDFMIAL GLECfR S .14.
not mart run five hundred dollars ycinp.
Cm ❑ Lxsowncmpbcpnslxny,ormynnployees with wages mthcirsolecumpenzmion, Q STORIES ••TYPE CONSTRUCTION
a3— willduthe wort,and the structure is not mmndcdmoffpr d forsa,(Sm.7(K4.Business `
and ProNsslons Code:The Contractors License Law does not apply to an owner of
pni who buiIdsmimprovesthereon,and wondo seen work himalfortarngh his
own employees,4rovidod that such improvememre sanot lntendedoroftbted forsale.If.
OCC.GROUP RES.UNITS
however,the buildingor impfovemeni Is sold within one year ofnm+pletion,thenwner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale). QTY. PLUMBING PERM IT FEE FLOODZONE APN
❑ I,asownerorthepmp ay,amexclusivelycontmctingwimlicensedconw ionto
instruct the project(Sec.7047 Business and Professions Cade:)The Commences
License Lawdox not apply man uwncridpropcny who buildsorimpoevesthemon.and PERMIT ISSUANCE
Who commas(or each projects with a comemrod licensed pursuanuotn Compacta- ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Liceme Law.
❑ 1 and exempt under Sm. .B&P C for this reason O BACK FLOW PROTECT.DEVICE 9"IDL I EES
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RPCLIITk
co WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm thatl haveattnifcate of consent lm self-insure.maceni0cute of FIXTURES-PER TRAP RECEIPTM
Workers Compensation Insurance ora cenifiN copy theaof(See.3801).Lab C.)which PARK FEE Y N
rs all employee's under this permit. GAS-F.A.SYS'I'ICM-I INC.4 OUTLETS RECEIPT M
Policy p BUILDING DIVISION FEES
Company 6?40 r/(-d! GAS-EA.SYSI EM-OVER 4(EA) PLANCIIECK FEF.
❑ Cenifinl copy is hereby fumishel,
Certified copy is filed with the city inspection division GRF.ASIFINDUSTRI,WASTE INTERCEPTOR GRADING FEE
/l CERTIFICATE OF EXEMMON FROM WORKERS' GRF.ASETRAP SOILS FEE
COMP If SATION INSURANCE
(This section need not becompleled ifthe permit is for ane hundred dollen(SI W) SEWER-SANITARY-STORM PA.214117. ENERGY FEE
s.)
I certify that in the Performance of the work for which this permit is issuW,I shall WATER IIFATFR W/VEM'/ELECI'R
not employ any person in ony manner so us U md jam to the Workers PAID
Compensation Lawson Califg
omia. Dae WATER SYSTEM/TRFATING Mute Receipt it
Oz Applicant NEW RESIDENTIAL PLM B. SQ.FT. TOTAL: (j.Z
z O NOT'ICF.TO APPLICANT:IL after making this Ccrtificem of Exemption,you should
become subjmumthe Worker's Compensation provision of the Labor Code,you must
� ? fon,aitb comply with such pruni,mns or this Permit shall be deenudme.lood, BUILDING IEE
1 p, CONSTRUCTION LENDING AGENCY SEISMIC FEF. s
U2 I hereby affirm that mere is a conversation lending agency for the performance or
U TOTAL: ELECTRIC FEF:
O the work for which this Permit is issued(Sec.3097.Civ.C.)
Lenders Numc PLUMBING ITE
U" F Lenders Address QTY. MECHANICALPERMIT FEE
O U I certify mal 1 have mad his application and slate That the above information is MECIIANICAI.FEE
>4 W correct.l agree to comply with all city sod county oninances and sum laws relating to PERMIT ISSUANCE
F-' bmidingcorrso-umion.mdherchyuud izco,raserstrusesmfmis city teenmrupon the CONSTRUCTION TAX
rJ z above-mentionel property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree ,,save,indemnify and keep harp len the City of Cupertino against
Iiabiliticajudgmems.cwisand expenses which may in any way accrue agaimleaid City AIR HANDLING UNIT(To LOAX)CFM)
in consequence of the granting of mis permit.
AIR HANDLING UNIT(OVER I0,000 CFM)
Signature of Appliesm Conamplor Dam EXHAUST HOOD(W(DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Romiplk
Will the applicant or future building occupant store or handle havrdous material HEATING UNIT(OVER 100,800 BTU) TO IAL '
as defined by the Cupertino Municipal Cade,Chapter 9.12,and me Health and Safety
Code,Seeded 25532(a)'1 VENTILATION FAN(SINGLE RESID)
El Yes bi•N. ISSUANCE DATE
Will the applicammrfuture buildingoccupantusecquipmentordeviceswhichemit BOILER-COMP(311P OR 100,000 BTU) P A B D
husurri air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
DrsWcR
❑Yes 1KNo NEW RESIDENTIAL MECH. SQ,FT. DEC 2 R v 'I(�o IJJ3
1 have toad the hauNous mamria6 requirements under Chapter 6.95 of the
Calif nrnin I Icalth&Safety Qde.Sections 25505,25533 and 25534. I understand that
ifthe building does not comedy have a tenant,mat it is my resmosibilay to notify the CIIY yr vwrtr111NV
occupant of the requirmnems whi must he met p/rjpf m issuance of a Cenificde of
y d1z=/�� `�L ��l✓Cl
Owner mom4u ager Date TOTAL: ISSUED BY:
OFFICE