25335 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 25335
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CITY OF CUPERTINO PERMIT NO, L VI(� I( ^r�
V V
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
NA �DING ADDRESS:
`1I y SANITARY NO. APPLICATION SUBMITTAL DATE
O �^' l UNIT# LOT# �
BUIL � _
OWNERS NAM PHONE: CONTRA OJZ'S LIC NO:
✓_ T/IL 3 NIC CONTROL#
'• ARCHITECT/ENGINEER: LIC NO - ADDRESS ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE
BLDG I ELECT PLUMB MECH
LICENSED CONEl E-] ❑
TRACTOR'S DECLARATION APPLLINCHS-RESIDENTIAL
pCZ Ihereby 700miffirmthat l amlicensed Bminder prat Prifesion.Codes.And
(commencing se with TOB DESCRIPTION
+100 Section]WO)of Division3of lM1e Business and Pmfessians Code and my license is in PANELS
UUG fullarse sande t.,
w
E-Zm Claes Li,# UPT0200AMP1
GG=y me "'a'- 201 m 1MAMPS
Z�yz ARCHITECTS DECL ION OVER l000 AMPSSQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plans shall be used as public awards.
SIGNS ELECTRICAL
4 u❑�j Lmensed Profess%onel
�JOWNER-BUILDER DECLARATION SPECIALCBtCUIT/MISO
OyFa
1 hereby affirm that 1 Am exempt from the ContrwAm's License Law for the , 1
W 3 to following reason.(Sermon 7031.5,Business and Professions Code:Any city or county TEMP.METER OR FOUR INST. /
0. whichrequiresopermitin reconstruct,alterimprove,hpeolmstorrepairanyswnure _1 a6/�,3
prionnits issuance,elsorequiru Ne applicant fnr such permitmfileesigned statement PoWER DEVICES /
OO Nat he is licensed pursuant to the provisions of the Connactofs License Law(Chapter DATE
e 9(commeacimg with Section7")af Division 3 of the Business Add Professions Cade) SWIMMING POOL ELECTRIC III, VALUATION
,gym or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F < Sortion]03 LS by Anyapplicant fora permit subjects the Applicant A civil Penalty of OUTLEfS-SWITCHES-FIXTURES
p not more than five hundred dollars(550f.
W ❑ Lasowneroftheproperty,oro ero to ces with we esastheirsolecompensadoa, a�ID�T[Ad-Y P Y dSTORIES TYPECONSTRUCTION
will amhe wons C d o: structure actors Licee se Lae docs n tapplde y to an Business
-, and Prty wh ons Cade:The ves do ema,License Lew dces not apply sa an owner of
isproperty whobuildsorimproves thereon,antl who dces such workhimalforthroughhosemployees,prog Ori provehmmpmvementhin neyearndeaorof(tired theo n r- OCC.GROUP RESANITS
however,the building ar improvement ms sold within oneyeatofimproe for the owner-hnilder will have the burden ofproving that he did not build or improve for purpose ofD1❑ I,ct the pr ject(Sm.7044.Busin sis ayconvactiiousCo o:)Tit cConfit orsm QTY. FEE FLOOD ZONE gpry
License the project(Sec.oAno Business And Professions Code:)The Cortisone
License Lawdoes rsuch Pplytoawith Arofpropertywhnsed puodmprothe thereon,And PERMIT ISSUAN
whonse Law.forsuch projcens with a connector(%)licensed pursuant ro the Convector's
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this rerun BACK FLOW PROTECT.DEVICE IDE FEES
OwnerSANITARY Y—N—
Date. DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT is
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ ers'Com,cosnon Insuall veecorta sere of consent pythro xl(Sm.3,0r acec.)whichc.f FIXTURES-PER TRAP RECEIPT#
Worker%Comlaneciorderawearacenified copy thereof(Sec.3g00,LabCJwhich PARK FEE Y—N
—
Policy
all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA)
❑ Certified copy is hereby famished. PLANCHECK FEE
❑ Certified copy is filed with the city inspection division, GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section neednotbeeompleted ifthe Permit is foronehundsoldollers($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in ate perfamince of the work for which this permit is issued,Ishan WATER HEATER W/VENT/ELECTR
not employ day person in Any maturer so As to become subject to the Workers PAID
z CCompens'tmon Lawsof Califnnia. Date WATER SYSTEM/IREATINGApplicDate Receipt#
C, NOTICE TO APPLICANT:If,After making this Certificate of Exemption,you should NEW RESIDENTIAL PL HL SQ.FT. TOTAL:
T-. H become subjceno the Worker's Compensation Provisions of the Labor Cade,you must
[ai forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
pW, O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that thea ms a construction lending agency for the performence of
the work for which this permit is issued(Ser.3097,Civ.C) TOTAL: ELECTRIC FEE
Len .y Lenders Name -
U Lenders Address QTY. MECHANICAL 210.W�)
FEE PLUMBING FEE
W 1 certify that 1 have road this application and sense that the above information is MECHANICAL FEE l
tract.l agree to comply with all city And county Archaancesand state laws relating m PERMITISSUANCE
building cons a hereby Anthormzere enoavee ofthisOty-AnIeruponthA
L) z� above-me netl ny fnr ins tionp ALTER OR ADD TO MECH. CONSTRUCTION TAX
( e)agree t save,
or and armless Ne City of Cupertino against
b.bilin s,ju ms,co is andx s h' may in Any way acemeagainst said City AIR HANDLING UNIT 1
in consequ of the an of Is t.
AIR HANDLING UNIT(OVE
A
ignam of Applicam/Contractor Data EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applirmu or fr.building occupant sore or handle hazmdoA%mmerial HEATING UNIT(OVER 100.00E BTU) TAL:
es defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
Will the applicant orfuturcbuildingoccupent u%eequipmentordeviceswhichemir
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Lhazardous air contaminants as defined by the Bay Area Air Quality Munagememr BOILER-COMP(OVER 100,000 BTU)
M,Het? Yes ❑No NEW RESIDENTIAL MECH. $Q.FT. PAreadthe hazardous materials requirements under Chapter 6.95 of rhe ,7eahh&Safety Code,Sections 25505,25533 and 25534.1 understand thatg dces not currently have a tenat,than it is my responsibility to notify thethe requirements which must be met prmo mssuance of a Certificate oartxa agent Dam o IssupD BY: JV�•(Ir,I+T,(l, "lily