25054 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I•DING- MI A• PERMIT NO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECY'IDENTIFICATION
54
BUILDINGAUDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
11145 Sr 3
LOT It
OWNERS N ME: PI{ NE CONTRACT S NAME: ,/LIC NO:
�� /- LV -u NA] COI OLM
nRCHITECI/P GINEER. C NO: ADDR SS: ,/n ❑
CON'I'ACI': PHONE:
—06-4? QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCII
PERMIT ISSUANCE � ❑ "tj ❑
LICENSED CONI'RACE OR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz Ihereby affirm that l an licrrocdundcr provisionsof Chapter 9(cnmmencing with JOB DESCRIPTION
k100 Section 2lhxq of Uivisinn3of the Business end Prolessions CsJe.aA mylicense is in PANELS
,ad full force and effect.
FzU me Class Lic.N UP TO 200 AMPS
ky ice ��'a`
N< Dam Comma., 201-1000 AMPS I '^
ZO�! understandns ARCHITECTS DECLARATION OVER 10(d)AMPS SQ.M.ILOOR AREA $/SQ,FT.
CZ-0 1 understand my plashall be ued sas public records,
F F' SIGNS ELECTRICAL
ZY$J Licensed Professional
C
eQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyF I hereby affirm that I am exempt from the Contractor's License Law for the
Wy following reason.(Section 2031.5,Business and Professions Code:Any city or county TEMP.MF'TER IY s .A
La:o l which requires u permit u1 construct,alter,improve,demolish,or repair any snucturc
,WaM prior to iv issuance,alsorcyuires the applicant for.such Permit file a signed statement POWER DEVI O
kI�MO tout he ix liccaedpursuam to the provisimeof the Contractor s License Law(Chapter
�-%oEl 9(commencing with Section 7")of Division 3 ofthe Business fund Professions Code) SWIMMING PO ELs I�� VALUATION
WM, or that he is exempt therefrom and the basis for the alleged exemption.Any violation.( OUTLETS-SWI'IC TURFS '
F_Z Q Semina 2031.5 6y any applicant for a pemmid subjau doe nppli<ant do a civil penalty of
¢ rpt more than five hundred dollars($5010).
K I-o ❑ Lnsownerofthe norm to eeswithwa csasdhcirsolecom NEW ftEYT1AL ELECIit _SQ.FT. TYPE;CONSTRUCTION
grope y yemp y g pcaation, STORIES
y30O will do the work,and In,smlume is not intended proffered forsalc(See 2044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
pmpcny who builds or improves thereon,and who does such work himself or through his
ownemployces,provided that such improvemenuare not intendedoroffcred foraale.If. OCC.GROUP RES,UNITS
however,the building.,impmvemem is sold withinnneyearofcmmpletion,the owner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
sale.). .
❑ I,as ownertlfmhe property.ten exclusively contracting with licensed contractors to QTYPLUMBING PERMIT PEE MOOD LONE, ppN
combat,16e Project Sm.2044,Business end Professions Call The Cotracto
nr's
l icense lawdcesnot apply man ownendpropcny who builds orimpnwes thereon,andPERMIT ISSUANCE
who contracts forsuch hojem,wil somme ctorls)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY
❑ 1 nm exempt under$cc. ,B&P C for leis reason BACK FLOW PROTECT.DEVICE: OUTSIDE ..S
SANH'AKY Y N
Owner pate DRAINS-FLOOR.ROOF,AREA,GOND. RECEIM.It
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX Y__N
❑ Ihereby of firm Oleo lhave acenificme of consent o,lf-insure.ora cenificam of FlXTURES-PER TRAP RF-CEIPTN
Workers Compensation Insurance cracerified copy lhucof(Sac.3800,Lab C.)which PARK FE=FEE _
rivers all employees under this permit/ GAS-EA.SYSTSiM-I INC.4 OUTLETS
Policy p ES
Company GAS-EA.SYSTEM-OVER 4(EA) PfANCH
❑ Cerified copy is hereby famished.
❑ CcnificJ copy is filed with the city inspection division. GRIiASE INDUSTRL WASTli 1N EERCEPfOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' DEBASE TRAP SOILS COMPENSATION INSURANCE
fnissectionnced nm hcpridend iftheperrnil isfornnehumboddi lars($IW) SEWER-SANITARY-STORM EA.300177, ENERGY
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WNBNT/f;LECI'R
nm employ any pen'on in any manner so it, to become subject to the WorkersPAID
O z Compenstati.nlawsof Califomla. Date WATER SYSTEMMEATING Uate Rcceiptp
O PP
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
H > bcehwithc reply the Worker's Comms or this
perms shall bed Lubar Coked. must
� , forthwith comply with such provisions or permit shall be deemed revoked. BUILDING ftiE
y O CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 herchy affirm that them is u construction leading agency for the performance of
V O the work far which this pea itis i...ed(Sm.3092,Ci,C.) TO ELECTRIC FEE
Lender's Name
0 F Lender's Address QI'Y. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 verify that I have teed thisanpl emion fund swte that the above information is
Ir" ennem. lagree it,comply with all city and county ordinances and stain lows relining to PERMIT ISSUANCE MECHANICAL FEE
_ buddingeore and hereby amhodu reprcsenmtivcs of this city toenter upon the
U z above-mc ncA ry for inspection laureates. M
OR ADD TO MECH. CONS TRUCfION TAX
^ '1c,'
c7 a c �Icx�snfficiry of Cupcninp egvnsthdIu i r Is cad d swer.c.,madsaidCil, DLING UNIT(TO 10,0WCFM)on I f the 5 -7 DLING UNIT(OVER IO.OgI CFM)
rates
' r um of Applican4C.ntracmr Date ST HOOD(W/DUCH
PAID
HAZARDOUS MATERIALS DISCLOSURE G UNIT 100.000 BTU) Dole Receiplp
Will the applicant or future building occupant store or handle harard.us material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety If UNIT(OVER IW.00(1 BTU)
Code,Seaton 25532(n)'t
❑Ycs ❑No ATION FAN(SINGLE RESID)
• will tra,co icamnmr,as building occupant.,Area
Air Quality Managerrit ment
-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
hairpiecDismO.s air amaminands as defined by dnc Day Area Air Quality Maagement -COMP(OVER 100,000 BTU)Disrlm) IQ❑Ycs ❑No SIDENTIAL MECH. SQ.FT. A Y1 have read the haardous materials reyulrcmems under Chapter 6.95 of the
Culifonlia lit he req Safety Csde,Sh .as'IN,met 25 nt 1.is2-5534of.Cirrs carte of1J(I fl� e 1�rat
if the building does not currently have a tand,that it is my msponxihility to notify thetu'/{ a1993
occupant nl the rcyuiremenu which must be mel prior to issuance of a Certificate of
Occupancy. /s11 y Uf 'L .
Owner or authorized agent Date TOTAL ISSUED BY:
OFF