25259 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICAI]ON 25259
BUILDING ADDRESS. ySANITARYNO. APPI.I �O�NSUtIT(A/r}LATE
RIC19 Q)D� Uwe UNIT# LOT# /
NAME: P ON& O C TORSNA :eprrjnt LIC NO:UVN/C CONTROLppm
ITECf/L'NGINEER: LIC NO:
CONTACT: PHONE: " -L"^ BUILDING PERMIT INFO
Q4T�Y' wGTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ El
LICENSED CONTRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
coez ThembyaffirmlhallamlicensedunderprovisionsofChapter9(commencingwim
e1400 Seamon]000)of Divixmr3 ofthe Business and Professions Code,andmylicemse is
full force and off — PANELS #
6FzuVj Livens Suss Li<.p UPT020(i
stFn.66=ve
Due Contmcmr 201-1000 AMPS g FT.FLOOR AREA S/SQ,PT.
ZO,i�IZ ARCHITECTED TION OVERI""PS Q'
0Z_Q I understand my phis shall b,ase as public records.
hs�,1{l SIGNS ELECTRICAL
a 6 Licensed Professional
Es mV OWNERTUILDER DECLARATION SPECIALCIRCUIT/MISC. r R # s
xOaF- I hereby dfirm that 1 an exempt from the Contractors License law for the l
W 3 LL m billowing reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INET.
O which reclaims a Permit m construct,alter,improve.demolish,or repair any structure fT--��
�€ T� in the licantforsuch m ,mfiletri uRmnt POWER DEVICES L✓
prior rsto the applicant pe goes Ill
ncj GpC that he isgein,wpursction theprovisions ofthe Ce Busiors License Law mCh err
a eLL 9(coinmencing with Sectian]OIX)of Division3of Ne Businasand Profeseirns Code) SWIMMMG POOL ELECTRIC
' _stn or Char he is<xempt therefrom and the hosier for the alleged exemption,Myvialation of OUTLETS-SWITCHES-FIXTURES #r
ZG Section]031.51 any applicantforapermit aubjav the epPlicentmecivil Tensity of
mart than five hundred dollars(5500). NEW RFSIDP.NTIAL ELECTR _SQ STORIES STYPECONSTRUC110N
pro ❑ I,esownem0heproperty,ormycmployeeawim wegesestheinolecompensetion,
o. will do the work,end the stmctum isnotimended reoffered fnsale(Sec.?044.Business
and Professions Code:The Contractor's License law does not apply m an owner of
pmpeny whabuildsorimproves dureon,andwhodors such workhimselforthrnugh his OCC.GROUP RES.UNITS
con employees.pmvidethatsuch improvereentsarenotm endedoroflend forsule.If,
however,the building or improvement is sold within one yew ideompletion,the owner
builder will have me burden of prising Out he did not build or improve fm purpose of TOTAL:
sale.).
❑ Las owncroftherropcny,amexclusivdy contrating with licease contractors to K,Y jk}.� -'BI:UMBING PERMIT FEE FLOOD ZO E "Nconcoct the project(Sec.70 ,Business and Professions Code:)The Conv¢tor's ., r r,,
Licenulawdoesnot apply manownerofsoperty whobuildsorimproves thereon.and PERMITISSUANCE
whoccntmcuforsuch pmjmts with acantrecmr(s)licensed pursuant to the Contractors ALTER-DRAINffi VENT-WATER(EA) FEE SUMMARY
License Law. � '�'I
C31 am exempt under Sm. ,B&:P C for this mason I BACK'FLOW PROTECT.DEVICE S
SANITARY Y N
Owner Dam RECEIPra
DRAINS-FLOOR,ROOF,AREA,CON I.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have a exrificsteafcomenno self-insum,ore crstificateof FIXTURES-PER TRAP RECEIPT#
Wmken'Compeitsuion lnsuunceora cenifie wpY
of(Sm 3800,Lab C.)which PARK PEE Y N
RECEIPT a
ars all ryeeluMer1sMis-mmtg..` _atia--w GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FEES
Poncya ., Il A)
Company k'tCY 1�Y1 S � GAS-EA.SYSTEM-OVER4 TEA) PLANCHECK FEE
d❑ Certified copy is hereby famished
Pl Certified copy is filed with the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This section need notbecompleted ifthe permit is for one hundred dollars(SUM) SEWER-SANITARY-STORM E.A.200FT. ENERGY FEE
am less.)unify nify that in the performance ofthe weak forwhich this permit is issue.)shall WATER HEATER W/VENT/ELECI'R
not employ any person in any manner u as in Ixcomo subject to the Workers PAID
Compensation Lawsof Califomis. Date WATER SYSTEM/TREATING Date Prompt It
0 Z Applicant _
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.FT. TOTAL;
r D� become subject to the WorkNs Comprmahen provisions ofthe Labor Cade,you must
forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
PW-i Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm mat there is a construction leading agency for the performance of
U O TOTAL: ELECTRIC FEE
the work for which this permitn Wooed(Sec.309],Civ.CJ
Lenders Name
I'L' Lendrre Address C�T1'. .( pMECHANICAL PERMIT" FEE PLUMBING PEE
C) V I cantly mar I have read this apphcatron and aura that the above information is
LkI coned e m
legrecomply with all city and county oNmanees and stenaw
ls rtMECHANICAL FEEleung to PERMIT �./
building construction,and hereby esu lacrim representatives of this
city to enter upon the CONSTRUCTION TAX
V Z above-mentioned prop err,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to true,indemnify and kap hasumbess the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
trance oI he granting of h's ma
yY AIRHANDLING UNIT(OVER 10,00JCFM)
Sin mod Applicant/Contactor I u EXHAUST HOOD(W/DUCp PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100,010 BTU) Date Rcceipta
Will the applicant or future building occupant nom or handle brow doss mmerial
m defined by e Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOO,WO BTU) p TOTAL:
Code,Section 25532p)? VENTILATION FAN(SINGLE RMD) A I D
❑Yes ❑No
' ISSUANCE DATE
Will meapplicantmfutare building acspastme,iii,eemordevices whichemit BOILER''-COMP(3HP OR tffl."BTU)
ha>abous air contwninuns as defined by the Bay Ama Air Quality Management BOILER-COMP(OVER 100,000 BTU) JUL 111994
�I Distrn?
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.Pfd
CITY Ur uvrcnwvU
1 have reed the hurSafety
Code.
materials 5505, 533 under Chepux understand
of the
ifuil ingHealtrudo&Safety Cada Samoan 25505,25537 and 25534. 1 understand m e
if the building does not meatscurrentlyw have a tenant,But o is my responsibility to notify the
Occupant of the rtquirtments which min be met prior to issuance of a Cmrificme of
oaapmtay. ,�/./��
Ownerormhodndagem Data TOTAL: ISSUED Pjt(