25106 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO B 1 -ica,ic,DUCAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25106
BUILDING PROJECT'IDENTIFICATION
BUILDING(A��DD/R�E�SS: ST SANITARY NO. APCWCATIONSUBMITPALDATB
�V �J r • UNIT. LOT J
OWNB iftl S18PH(9O;-1-
ONg ��^_ CONTRACTOR'S NAME: LIC NO:
`/�. N/C CONTROL#
ARCHITECf/HNGINEER: LIC NO: ADDRESS: - C1
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ' ELECTRIC PERMIT FEE
�T.9�/� S ELECT PLUMB MECH
pt�lp" / PERMIT ISSUANCE
-LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
71�
Ihandw.M.that lam fimmedunderprovisionufainner9(commenting with ]OB DESCRIPTION /`
IVOOSutian'/Iand of Division 3 of the Business and Professions Cade,and my license is in PANELS C L 1 �.►..�1
Poll fume and effect. J1f1� 1"",�\``�Jl-. ` J
License Cl Lia# 922? �-�''a IIP T02W AMPS Dae Contractor �+' 201-1000 AMPS
FO y,ZJN ARCHITECTS DE�ARATION - OVER Wild AMPS SQ.FT.FLOOR AREA $/SQ.IT.
O Z—G 1 understand my plans shall he used as public records.
rc, 0c SIGNS ELECTRICAL
2� Licensed Professional
mm OWNER-BUILDERDECLARATIONthe Contractors
SPECIAL CIRCUIT/MISC.
yy O y U 1 hereby affirm that I oro exempt from the C.sions C's Licenser Law for the
ti13 rFii following(ancon.(Section 7031.5,Business end Professions Code:Any city or county TEMP.METER OR POLE(NST.
O< which requires a Permit cor,
o construct,al ,improve,demolish,or repair any stmctme
NyeInform its issuance,also requires@e applicant for such permiuo file asigned sticment POWER DEVICES
4O that he is licensed pursuznno the provisions of the Contractor's License Law(Chapter
SWIMMING POOL ELECTRIC VALUATI
X� 9(comm isexempng thominn]WO)he Division 3oftheled exess it mptio.A.,vans Cade)
00
41.�.m onhat M1ele151, dominantandfor a permit
sfonhects theaexemption. .ivilp realty f
Sut'on]03 LS by any applicant farapermit subjects the epplicannoecivil penalty of OUTLETS-SWITCHES-FlXTURES
not more then five hundred dollars(§500).
G NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ .the wnk adthespec,ormyempendedinef wetfinsthei(sole compensation,
py will do the work,code:The Conure nector's
License
Lae does not
apply t oan Business I
and Professions Code:The Convaa.r'e License Lew does not apply to an owner of
pmpeny who builds mimproves thereon,andwhodoes such workhimselforthrough his OCC.GROUP RES.UNITS
ownemployces,providedthatsuchimpmvemeamamnotintendedoToffemdforsale.If,
however,the building or improvement is said within one year of completion,the owner-
TOTAL:
builder will M1nve 0e burden of proving that he did not builtl or improve for purpou of
sale.). FLOOD ZONE APN
- o- , ''
❑ Las ownerofthe property,an exclmovelycontracting with licensedconnecmrsto QTY. '„.,. PLUMBING PERMIT PEE '
untrue[the project(Sec.7094,Business and Professions CMeO The Contractor's PERMIT ISSUANCE
License Law does marto an owner of property who bui Ids or improves thereon,and
whocomracts forsuch projects with acontracmr(s)licensed pursuant to the Court ALTER-DRAIN&VENT-WATER Boa) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec: ,B&P C for this reason OUTBACKFLOW PROTECT.DEVICE SIDE FEES
SANITARY Y N
Owner
Data DRAT Ft ND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ (hereby affirm Natl heveecenificete of consenttoulf-insure,...cenificae of FlXT fB- SERT' FrD RECEIPT#
Workers'Compensation lreumnce or.unified copy the vf(Sec.3800,Lab C.)which -TT PARK FEE Y N
ars all employer's mdenbie pnmit. GAS-EA.SYSTEM-1 INCA T RECEIPT#
Policy# pp����CC BUILDING DIVISION FEES
Company AS-EA.prAT-F& V PLANCHECKPEE
'�Cerified copy Is hereby fcmishal.
fied copy is filed with the city inspection division. SE/INDUSTRL WA STEINTERCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is Forane hundred dollars($100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or lees.)
I unify that in the performance of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any marten so es to become subject 1.the Workers PAID
Compens.lionlawsof Celifomma. Date WATER SYSTEM/TREATING Data Reacipt#
Q ,z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMH. SQ.FT. TOTAL:
tibecome subject to the Worker's Compensation provisions of the Labor Code,you must BUILDING FEE
Lakl , forthwith comply with such provisions or this permit shall be demand revoked.
[] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby of on that there is a construction lending agency for the porfomanee of -
U O Ne work for which this permit is issued(Sec.3097,Civ,CJ TOTAL: ELECTRIC FEE
tr Lenders Name PLUMBING PEE
Lenders Address QTY. ".MECHANICAL PERMIT PEE
0 U 1 certify that I have read this application and state that the above information is " ` ' MECHANICAL FEE
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby.mhmizerepresentaives of this city to enter upon the CONSTRUCTION TAX
U7, .have-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We).gram 1.save,indemnify and keep harmless de.City of Cupemno against
liabilities,judgmen¢,ustsande.fous,`s whichm. ' ny waluum larmansaid City AIR HANDLING UNIT(TO 10,000 CFM)
in eousequ f]hc muting 9T4 6pernr AIR HANDLING UNIT(OVER 10,000 CFM)
Sig [ure of Applicalu/Cont Dote EXHAUST HOOD(WMUCq PAID
HAZA US MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Willfieapplicanto lure buildingoccupied store or handle hazadoas material HEATING UNIT(OVER 100,000 BTU) TOTAL:
es defined by the Cup, no Municipal Code,Chapter 9.12,and Ne Health and Safety
Code,Section 25532007 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will the epplicantorfumrebuildingoccupant useequipmentordeviceswbich emit BOILER-COMP(3HP OR 100,)00 BT H ISSUAr#iCEd1N A i M�V
hawNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,"BTU)
District? ECMAY 241993
❑Yes ❑No NEW RESIDENTIAL MH. SQ.FT.
_ 1 have mad the hasardous materials requirements under Chapter 6.95 of the _ ,aa�gyr r`r ����y�ly�i�/�]�,�'/Jr�(/��a
iftheuil Heath&of cur Cale,Sermons 25505.25533 and 25534. 1 understand that �y i T V f1' !
ifthebuildingdoes notcurrentlyyhaveatenant,thatitmyrearceiof iryenmifythe
occupant of the requirements which must be met prior w issuance of a Certificate of
Occupancy. MV/
Owner m amhodzed agent Date TOTAL: ISSUED BY: