25041 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION - -' PERMITNO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL. 1
BUILDING DIVISION BUILDING PRium r UDEN'IPICATION
BUa0Mc w4o•DRLSS: -' SANITARY NO. APPLICATIONSUBMIITALDATE
LOTH
OsVNRS NA 11�nn PHONE CONTRACTOR'S NAME: LIC NO.
svt - 2 �'���^�� v NIC CONTROL#
—�. R 1I T/ENGIN RCL: LIC NO: ADDRESS: 11� .
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
OG E{,EQI'
PERMIT ISSUANCE �� }LyTM`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LUMB EC
Paz Ihereby affirm that lam licensed underprovisinnsofChapter9(commencingwith JOB DESCRIPTION
0+100 Section]00Rcw Division 3 ofthe Business and Professions Code,and my license is in PANELS
5Ct full force and effect.
QZz, License Class Lic.# UPT020IIAMPS
rFii bon Dale Contractor 201.1000AMPS #
zOyz ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FE
C Y- I understand my plans shall he used us public records.
(_S SIGNS ELECTRICAL
Licensed Professional
�a OWNER-BUILDER DECLARATION SPECIAL CIRCIIIT/MISC.
O a F Ihereby affirm that 1 am exempt from the Cmntracmr's License Lew for the ^�
W 3O una following nation.(Section 7031.5,Business and Professions Code:Any city memory TEMP.hffiTEE OR POLE MST,
rn.l which requires a permit to construct,alter,improve,demolish,or repair any structure
1�w)Y,, prior to its issuance,alsorequiresthe applicant for such Permit tofile asigned smtement POWER DEVICES
G p
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter �r#$�
a 9(commencin with Section of Division 3 of the Business and Professintrs Code SWIMMING POOL ELECTRIC W
(commencing ) ) VALUATION
❑7�y orthat oheisexby therefrom and the basPermit subjensege aplica exemption civil
of UTLETS-SWITCHES-FIXTURES � /kyyy�l
Na Section 7031.5 by any applicantfor apertnit subjects the applicanttoecivil penalty of
re than five hundred dollars($500). NEW RESIDENTIAL ELELTR 5 .FT.
asowneroftheprop M,ormyemployeeswithwagesastheirsolecompemation, Q STORIES TYPECONSTRUCTION
E. 4 II the work,andthe s[menta is not intendedoroffered(.,sale(See.]044,Business -1
and Professions Code:The Contracmes License Law does not apply to an owner of
property whobuildsorimprovesthereon,ad whodoessuchwork himselforthroughhis
own employees,ptovided Nat such ImpmvementsarenothttrndMd offeredfors0e.If, nUQROU _ .UNITS
however,the btildingor improvement is sold within one year ofcompleoon,theowner- �(Jj'fff V�
builder will have the burden of proving that he did not build off
r improve for purpose of h V 0
soleTY, PLUMBING PERMIT PEE TE PLO APN
❑ Las ow profct(Sm. rt,14,Business
ontressions Code-)
he ontractsto Q
Limma,construLaw does not(Sec.]044,Business and Professions Code)Tae Contractors.
Weenie Law does not applytn arrownerofproperry who bonds orimproves thereon,end PERMIT ISSUANCE _
License
Lace fmsuch projects withacontrector(e)licrnsetl pursuanuo the Contrmtors ALTER-DRAIN&VENT-WATER FEE SUMMARY
Cleanse Law. (EA)
❑ I nm ex Sec. B&P C rm' reason BACK FLOW PROTECT.DEVICE OUTSIDE EE
�—� - SANITARY Y N
R MAN COMPENSATION DECLARATIONDRAINSFLOORROOFAREACOND
, , , I- RECEIPT#
t� SCHOOL TAX Y N
❑ I hereby affirm thatlhaveecerti0cate of Anomic self-insure,orecenificete of -�� RECEIPT#
Workera'Compensation Insurance ora certified copy thereof(Sec.3800PER TRAP,Lab C.)which FIXTURES- PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTq
Policy at BUILDING DIVISION FEES
pany
0 Conified copy is hereby famished, GAS GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE O
Cert
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE ire
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(T'his section need not be completed Huss pertnitis for one handrail dollars($100) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
Icertify thrumtheperfcummumofthe work forwhich thispennitishatied,Isbell WATER HEATER W/VENT/ELECIR
not employ any person in any meaner so u to become subject to the Workers' PAID
z Cnmpensition Latwsof Cmifomla. Date WATERSYSTEWIKEATING Date Receipt#
Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ,FT. TOTAL:
..-I become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such Provisions or this permit shall be domed revoked. BUILDING FEE 7.1 a,sas
LSI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE LO
z 1 hereby affirm that there is a construction lending agency for the performance of
U O the work for which this Proud,is issued(Sec.301 Civ.CJ L: ELECTRIC FEE '��•
Lendefs Name PLUMBING FEE
0 U Lender's Address QTY. MECHANICAL PERMIT FEE
1 certify that I have read this application and sum Nat the above information is
correct.l agree 0 comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEEast
0 —
building construction,andhereby authorize representatives of this city toenterupon the CONSTRUCTION TAX
U 7 above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
F7 (WZM
e,ioncom yand keep harmless the City of Cupertino againstliabilities, osis and ex hich may in any way accmeegvratsaid City AIR HANDLING UNIT(TO 10,0(10 CFM)
in con e v noting f perms. AIR HANDLING UNIT(OVER Io,000 CFM)
angContmctor '7 Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building Occupant erre or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) A
Code,Section 25532(x)? VENTILATION GAN(SINGCB REBID)
11Yes ❑No
3 to
BOILER-COMP IMP OR 100,000 BTU) ISSUANCE DATE
WilHheepplicanmrfuwrebuildingacupent useequipmenmrdeviceswhichemit PAID It air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A
strict? n
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. MAY - 999
I have read the hazardous materials requirements under Chapter 6.95 of the M
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
lime building due.,nm eumanay have is main,that 1,is my respmdulity to nmifyme C'IJ-I Ur Wrrril
Occupant of the requirements which must be met prior 0 issuance of a Certificam of
PV
Occupancy.
Owner or authorized agent Date /� ISSUED BY: �V ,