25479 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIO PLUMBING-P.K.ru ICAL PERMIT No.
NO APPLICATION/PERMIT Q
BUILDING DIVISION BUILDING PRECT IDENTIFICATION V
OJ
BUILDING ADDRESS. ,�/[p SANITARY NO. AYPLICA'I ION SUBMITTAL DAD
10 • v LOT#
O SNA is `S / 6TNE7 CO OR'S AM `LIC NO: VVV
.YII I GL N/C CONTROL#
•ARCH ITECf/ENGINEER: LIC NO: ADDRESS: ❑
J CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pWZ Ihereby affirm that T am licensed underprovisions of CTaptor9(crmmeneiagwith
1+100 Scction](Mp)of Division3nf the Business and Rrfcsaions Code,antl my licca-is in pgNE1S
sF. full force and affect.
FGw Liam ,0s Li .# IIP TO 200 AMPS
yah Date DASD 201-IOW AMPS
J FO y z' TF S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1 undersand my pl shat he used as public rods.
F..rn C W SIGNS ELECTRICAL
Licensed Profcsaional
CW6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oyu I hereby effirn that 1 nm exempt from the Courtrai License law for the
W O y following reason.(Section 7031.5,Business and Profusions Code:Any city or county TEMP.METER OR LE ST.
which requires a permil m umatruc6 alter,improve,demolish,or repair say structure
prior no its isomerism.also requires the applicant for such proof to file a signed statement PoWER DEVICES I tl r t_ I N I
ty W G p that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter 0 V
di9(commencin with Section 7000 of Sof the Business and Professions Code I i
KO� (commencing )° ) SWIMMING POOL ELE 1 I i �I -I VALUATION
W M,,
or that he is excmpuhcrefrom end the basis for the alleged exemption.Any violation of OUTLETS-
FZ< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of SWITCHES-FlXTVRF$
ma mart than five hundred dollars(5500).
Win n ❑ I.asowncrrfthe t yemp Y agesm pensatirn, NEW RESID11
ENTI ELECT ATF SQ.
proper y,rnn to cera withw thejrsrlecom ST RIES TYPECONSTRUC IM
y3— will do the work,andthesrumure is not imenxcloroffcred forsale(See.]044,Business
and Pmfasions Calc:The Contractor's License Law does mol apply m not owner of
property who builds or improves thereon,and who does such work himself or though his
on employees,pmvided that such improvements are not intandedoroffered presale.If, OCC.GNOUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,tharoxim- TOTAL:
builder will have the burden rf,mvia,that he did not build or improve for purpose of
side.).
❑ I,m ownarrthapropeny,am eaclua;veycontactingwith licensed wnvacmrsto QTY, PLUMBING PERMIT FEE FT.00D ZONE APN
raatrvm the project(Sec.70,t4,Business and Professions Cu&)Tae Contractors
License law does not apply toanownaroffarc y who builds or improves Hereon,and PERMIT ISSUANCE
wh°rontmer,mrsuch projects with acontractor(s)licensed promentm the Contractors ALTER-DRAIN&VENT-WATER
License Law. (EA) FEE SUMMARY
❑ T am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT'.DEVICE OUTSIDE FRES
SANITARY YN
Owner RYIDam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT-
• c WORKMAN COMPENSATIONDECLARA'1'ION SCHOOLTAX Y N
❑ ero'Co affirraion Insurance orificmeof<mpentmsd(Sor.rg0.aanifi ate ofwhich FIXTURES-PER TRAP RECEIPTp
Worker Compyee'snler this Permit.
certified copy thereof(S<c.3800,Lab CJwM1;ch PARK FEE Y N
all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEHvF#
PORGY- BUILDING DIVISION FEM
any
Certified crvr is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is Tiled with the city inspection diviai°n. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This sectionaced nm becompleted ifthe permit is for ora hundred dollors($IW) SEWdl- ANITARY-STORM EA.2WF7. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued.l shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensationlawsof California, Dare WATER SYSTEMAREATING
0 Z Applicant Dare Receipt#
z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f—' (/] become subject to the Workers Comparison.pmv;siras of the Labor Code,you must
Q4 7 firrt with comply with such prig afire or this permit shall he deemed revoked.
BUILDING FEE
Fk] Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a coratructioa lending agency for the performance op
V O the work for whieh,hic permit is issued(So 3097,Civ.C.) ELECTRIC FEE
Lender's Name
U.
U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �..
1 certify that I have read this application and stare that the above information is
correct.l agree to comply with Al city and county ordinances and sate laws mining to PERMITISSUANCE MECHANICAL FEE
building construction,and hereby nuthodze representstivesofths city to emerupen the
V Z above-mamioned property for inspection purpuras. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree or save,indemnify and kap hmmiess Ihn City of Cupertino.,.just
P
s,costaamdexpenaes which may in any wayaccmeaainst said CjtAIR HANDLING UNIT(1010,"CFM)
irf of t grantingofthispo mit. AIRHANDLINGUNIT(OVER IO.t]W CFM)
p want/Ci dn. Da¢ EXHAUST HOOD(W/DUCpPAIDIfAZARDOU9 MATE RIALS DISC LOSURFe HEATING UNIT(1'O IOO,WO BTII) Dater ReeeiptMal applicant rr future building occupant atom m handle hazardous material
as defined the Cupertino Municipal Coder,Chapter 9.12,and the Health and Safety IIEATING UNIT(OVER 1 Of,"Of,"BTU) TOTAL:
Cada,Sea rnim25532( '1
e)
0Y<s ❑No VENTILATION FAN(SINGLE RISID)
Will the applicant or Tatum buildingacupantuuequiptrtenmrdeviceswhichemit
BOILER-COMP IFTOR IW,(100BN) ISSUANCED 'E
Intruders air comamiwms as defined by the Bay Are.Air Quality Management BOILER IW,000BTU)
Dis ct° P A '
❑Yea ❑Nu NEW RESIDENTIAL MECH. SQ.FT. D
1 have read the her ordous materials mquimmms under Chapter 6.95 of the
Calif°mia I No&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat �uG 2 31993
if the building does not currently have a tenant,that it is my resp:maibiln,to notify the
Occupant of the requirements whieh must be mel prior to issuance of a Certificate of
ccur nt,
Owner or authorzed agent Dare CITY �tr k • : .
TOTAL:1 ISSUED HY: