25347 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11......HTG-ELECTRTI FERMI"r NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25347
IIUII.BING PRO.IE('T IDENTIFICATION
BUILDING ADDRESS: //// SANITARY NO, APPLICA'DON SUBMITTAL DATii
1203 I orkfX.re DIP— . UNITY LOT#
OWNERS NAMy . Aqry I PHONE, f_/?� CONTRACT O 'S AME: LIC NO: NIC CONTROLp
A RCI 111'ECT/lINGINEER: L LIC NO: J ADDRESS: ❑
COMPACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
C PLUM11 I
PERMIT ISSUANCE
LICENSED thtIaCONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL �� DESCRIPTIO
pKZ IhercbyaffiwCONITRACTOR'Sm licensed DECLARATION
gwith Ij
tUC)2 Section 7o00)df Division 3 ofthe Business and Probeasions Code.and my license is in PANEM
FC W full forte and effect.
QZty License Class Lic.# UP T02W AMPS
=< Carries
m Carries 201-11100 AMPS
ZFON ARCHITECTS DECLARATION S OOR AREA $/SQ.Fr.
0OZ—C I undersand my plans shot]be used u public..Ms. OVER 1000 AMPS
F rn t W SIGNS ELECTRICAL
Licensed Professional
its: OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. QS/
X�dpa,V I hereby affirm that 1 am exempt from the Contractors Liunm Law for the /
W 3 a y following mason.(Section 7031.5.Business and Profusions Code:Any city or county TEMP.METER OR POLE INST.
v' which reymires x permit to conswct,alter,improve,demolish,cur repair any sweturc Y/
�tzy�}� pni.nnim issuance,also requires Ne applicant lm such parotin.Ele xsigned saament POWER DEVICES
C CC) that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
dkp� 9(commencing with Scetion 7000).(DiOsdm3ofdm Businusand Professions Code) SWIMMING POOL ELECTRIC LUATION
Seen..7031.5 by anyaor that he is exempt therefrom end the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES OD
�ZG pplicnnt fora permit subjects theapplicarm toe civil pemllyof
� 0 not more then five hundred dollars(5500). NEW RESIDENTIAL ELELTR S .FP.
ap ❑ 1,the wrk,and epropeny,ermyempl0yeeswithwegansthe(Ses.c0mpcnshours Q STORIES TYPE CONSTRUCTION
3=° will do thework,rode: he Conttructure ractors
License
I.miemosnot apply 1044,Business
pandro Proerty wh ons Code:The Comacmrs nd who law ds not apply m rt owner of
own enywhers,proorimpmves Nem rove whodoes; himmlfonhrn.ghhie
employces,providedtlmt such improvements.coot intended oroffcmd forsele.If, OCC.GROUP RES.UNITS
however,the huilJingor improvement is sold within oneyear.fcompleti.n,fliamo er-
builder will have the burden.fproving that he did not build or improve for purpose of TOTAL:
avle.).
❑ Las.wner.fthe property,amexclusively convening with licensed contractors to QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.704,Business and Professions CW.:)The Contractor's PERMIT ISSUANCE
License Lew does nm apply m an.warr dlpr.,ny who builds or improves thereon.send
who camoram for such projects with acomracmr(s)licensed pursuuntro the Contractor's
License Law. ALTER-DNAIN&VLNT-WATER(FA) FEF,SUMMARY
❑
[am exempt under Sec. ,13&PC for this mason BACK PLOW PROTECT.DEVICE D MES
SANITARY YN_
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT It
WORKMAN COMPIWSATION DECIARA'1'ION SCUOOLTAX Y N_
❑ Ihercbyufrimlthailhavevicenifcamofconsemmselbinsurgoracenifcmeof FIXTURES-PERTRAP RECEIPT 4
1V.,kv.Compensation lmumnceoracenifnl copy thereof(Sec,3gfXl,Lvb C,)which PARK FEE Y N
covers all employeex under this permit. �JBGAS-FA.SYSTEM-1 INC.4 OUTLETS ItECEI Pr o
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTENFOVER 4(EA) PLANCHECK HE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. ORGSEIINDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompletedifthe permit is border hundred dollars p$IW) SEWER-SANITARY-STORM EA.200FT. ENERGY HE
or Jr..)
I unify that in the performance ofthe work forwhich this permit is iamed.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any msurd er sec as m barn.subject to the Workers' PAID
Compenvtion Lawsof California. Date WATER SYSTEMGREATING Date Receipt#
O z Applicant
z 2 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
rrn became subjut to the Winters Compensation pmvisima of the labor Cade,you must
a ? foMwith comply with such Persist......his permit shall ba derancd invoked. BUILDING FEE /a
1 Q CONSTRUCTION LENDING AGENCY SEISMIC -HE
Z 1 hereby affrd that them is a comwaion lending agency for the performance of —�
V O the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC HE
Lenders Name PLUMBING FEE
0 U 1 <ndds Address QTY. MECHANICAL PERMIT FEE �—
V I croify that I have mad this application end state Jin the above information is
correct.l agree to comply with all city and county ordinances and stale laws relating to PERMITISSUANCE MECHANICAL FEE
F-' building conswction,and hereby radiation representatives ofthiscity locator upon the CONSTRUCTION TAX
V z above mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify end keep harmless the City of Cupcnim,xgvinst
Iiabilitics,judgmenn,costs andrxpcnses which may in any waymeruexgainnmid City AIR HANDLING UNIT(TO 10,000 CFM)
in6^ft�it.m �t
AIR HANDLING UNIT(OVER I0,000 CFM)
Srgnamrc of ApplicenUC.nwcmr Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building.......nom m handle harmonicas material IIIiATING UNIT(OVER 100,00s)BTU) T
IfMT
❑
as defined by the C.,r inti Municipal Cade,Chapter 9.12,and the Ileahh and Safety
Cade,geed ElYca 13 No on 25y32(e)7 VENTILATION FAN(SINGLE RPSID)
Will lair co icvmm oras defined by the Bay Arco rir orathly whichemil
BOILER-COMP(3HP OR 100,04))BTU) ISSUANCE DATE
Di,bicnox air comeminanm u defined by the Puy Arco Air Quality Mena6cment tlOILh:R-COMP(OVER 100,000 BTU) P A U
l Disvim7
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. JULI have read the hasuNous materials requirements under Chapter 6.95 of the 1111'1 2 2 1993
Ca11I'.miu Hudth&Safety Cnde,Sectiore25505,25533anJ25534. Iundemninfilom VV -
if the huilding Rocs not currently have.mart,that it is my mspmsibility to notify the
cupamt.I'the requirements which must he ma prior to issmmce of a Cmifcum of y� f. it;UFE�ttrnqu
Owner nr umh.riaed ng
.at Ilene .. TOTAL: Y ISSUED BY:30- i
OFFICE - _-