25831 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO EUILUIN(r PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C O O N
BUILDING DIVISION /� / B/UIILDING PROJE(:'1'IDENTIh'ICA'1'IOIS L J o J 1
�5 DING ADD ?SS: �y Z LrwOA 4-NN C,U S_ L_o SANITARY NO. APPLICATION SUBMITTAL DAT[
a#sa' h t L UNIT0 / LOT#
OWNERS NAME: PHONE: OPS7VACTOR'S NAME: LIC NO: N/C \\l "`���CONTR��cOLe��—
LA/i/VSuLq IdoPkfL 2Cu[.usuTS
•ARCIIITLCr/ENGINEEH: LIC NO: ADDRESSZlea: I H 41E,L LT.i7 7 ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
lzxz I hereby affirmshm l amlicensed underproviskinsofaupter9(commenting with
qbE Seldom
av]addefDivision Jof the Business and Pm(nsions Code,and mylianse is in PANELS
f GgUU fail License
CI add effect yJ}ti Lt UPT0200AMPS
License 1 Lie.#
=y Date ' - Contractor 201-I000AMPS
20y� ARCHITECTS DECLARATION OVER IOW AMPS SQ.IT.FLOOR AREA $/SQ.FT.
CZ-0 I understand my plans shall be used as public records.
W SIGNS ELECTRICAL
hQ r,3, � Licensed Professional
F,:C, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xx'Oe. I heady affirm that 1 am exempt from the Contracture Licarue law for the
W 3 LL y following season.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
��� which requires a permit to construct,alter,improve,demolish.or repair any structure; prior m its ismance.ilsorequires the applicant fmsuchpannitto file a signed satemem POWER DEVICES
a_a pK Nat he is licensed pursuant to Ne pmvisiom of Ne Conuacmrs Licrnx Law IChapmr
tiLx oLL 9(commencin9 with Section]000)of Divisian3ofthe Businev and Prafevions Cade) SWIMMING POOL ELECTRIC
ATION
W_rn or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F 4 lacuna 7031.5 by any applicant for a permit subjects the applicant a a civil penalty of
rqZZ� not marc than Eve hundred Dollars($50(d NEW RESIDENTIAL ELECTR
a' o ❑ I,uowneroftheproperty,ormyemployeexwiN wagesu Neirxlecompenxtion, 9 TYPECONSTRUCIION
will do the work,and the structure is not inanded proffered for We(Sm.7044,Business S�
and Professions Cole:The Conmactor's License Law does not apply to an owner of
poirmywhabuildsarimpowaidi em,and whadne,mehworkhimselforthmugh his RES.UNITS
con employees,provided Nat such improvements are not intended or ofPorcd for sole.If,
however,theldrading or improvement is said within one yearofcompletion,theowner-
builder .will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,mownerofthe property,an exclusivelycoreacting with licensed contrectorsto QT' PLUMBING PERMIT FEE FLOOD 20th APN
concoct the project(Sea.7041,Business and Professions Code:)'Ibe Contractor'sppRMIT ISSUANCE
Li cense Law does nm apply m an owner of property who builds m improves thereon.and
whocesumets forsuch projects with a cone ods)licensed pursuant to the C.naxtors ALTER (FA)
License law. FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reoson __ OUTSI
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Data DRECEIFT#
RAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Ihereby'ConaNneat Nmihave
rance or iftcateofwnxntmof(Sh .SI ora ani0nte of 0.ECEIPI'#
FIXTURES-PER TRAP
Workers'Cmployee fonder thus Insurance or fled copy theaof(Sec.38W,Lab C.)which PARK FEE Y—N-
1
_
cover all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CF.IFfp
Polic # BUILDING DIVISION FEES
Cu any GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified ropy is hereby famished.
Codified copy is filed with the city inspection division. GREAiEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
.CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbecmnpleted ifNepermit is forms,hundreddollan(SIM) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
m less.)
I certify that in the parma.00 of the wmk for which this permit is issued,l shall WATER HEATER W/VENI'/ELECTR .
not employ any person to any manner so as to become subject to the Workers PAID
ZCompensation Lawsof Califnmia. Date WATER SYSTEMrrREATING Date Receipt#
Applicant
Z�Z[�-i 0- NOTICE TO APPLICANT:IL ager making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t" rn become subject to the Workds Compensation provisions ofthe labor Cade,you must
forthwith comply with such previsions or this permit shall be deemed avoked. BUILDING FEE
6.
Til SEISMIC FEE
CONSTRUCTION LENDING AGENCY
z I hereby affirm that thea is acovwctian lending agency for the perfomance of ELECTRIC FEE
V 0 the work for which that permit is issued(Sm.7097,Civ.C.)
Lenders Name
O Fat
Lenders Address QTY. MECHANICAL PERMIT FEC PLUMBING FEE
L) 1 cemify that I have reed this application and ataa that the above information is MECHANICAL FEE
>. LiI correct I agree a comply wish all city and county ordinmces and state laws reading a PERMITISSUANCE
F-' y building construction,and heabyvutharivapaseaudi esafthis city tocnterupon the CONSTRUCHON TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to rave,indemnify and ke p hunnlese she City of Cupertino against
liabi'ties.jridgerems.r.micndexpense ch ma yin any wayaccrusagalnstsaid City AIR HANDLING UNII'(TO IU,Of10 CFM)
n sequence. e8, fin fthi is. ��-I0�
43 AIR HANDLING UNIT(OVER 10,000 CFM)
igmat u(ApplicuMCnntmcmr Date EXHAUST HOOD(W/DUCry
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.00()BTU) Date Reccipt is
Will the applicant or futureoccupant
building nate or m
handle hamate
rdous riel
as defined by the Cupcdino Municipal Code,Chapter 9.12,and the Heath and Safety HEATING UNIT(OVER 100,00)BTU) TOTAL:
Cade,Section 25572(4)? VENTILATION PAN(SINGLE RE.SID)
❑Yea ❑No
ISSUANCE DATE
Willtheepplicmtorfuwmbuildingacupantuxequipmentordeviceswhichemit BOILER-COMP(7HP OR 100,000 BTU)
• hmallous air contaminants as defined by she Bay Arca Air Quality Management BOILER-COMP(OVER 103,000 BTU) RS A
District? If- {r9
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FL
I have read the heurdous materials rte mannents under Chapter 6.95 of the DEC as 9 1993
cabmmia Health&Safety Code,Sections 25505,M573 and 25574.I undersand that
if the building don not currently have a tenant,Nat it is my responsibility to notify the
occupant of the requirements which must he met prim to issuance of a Certificate of CI I I ( r'4 III
Occupancy. V
Owner ter annum eed agent Date TOTAL: ISSUED BY:
OFFICE