25967 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINONu- PERMIT No.
APPLICATION/PERMIT - PLUMBING-MECHAnICAL 25967
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /�2e SANITARY NO. APMICATIONSUBMITTALDAV
a�LL UNIT# LOT#
OWN R N - - P ONE: CONTRACTOR'S NAME: t LIC NO:
r N/C CONTROL k
ARCHITECT/ENGINEER. LIC NO: A DA SS: Ayl ❑
IsA � o J
CONTACT: PHONE: J� O,B` QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO iiU J BLDG ELECT PLUMB MECH
_ PERMIT ISSUANCE f5(I ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IL-S
Opdz Thereby affirm that lam on
licensed underprovisionafChapter9(cunencingwiN JOB DESCRIPTION
F400 Sectio.1000)of Division 3 ofthe Business and Professions Code,and my license is in ppNEl$
FUF full farce and effect.
I-Z, LOg DIOIeneChes Lic.41on"nerr is l 13eP E UP o TO 20 Aitms
Z O v ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA $/SQ.FT.
O Z—O I understand my plans shall be used n public records.
SIGNS ELECTRICAL
�Q Licensed Professional
0. OWNER-BUILDER Ddue Cor TION SPECW.CIRCUIT/MISC.
0.xa�O a 4- 1 hereby affirm Net 1 an exempt from the Con[ors On License Law co Ne
W 3 rn following rens..(Section comms,Bminess and xv,derons Code:Any city.,stcounty TEMP.METER OR POLE INST.
which mqu'vee n permit m cmnswm,elm.improve,demolish,or repair any slruc[ure JJ�
?J IaN]Q� priorm its issuance,almohlites the n,Iic.tf...ch permit to file.eigned statement POWER DEVICES
pp"�j3OO That he is licensed purmant to the provisions of the Commerce License Law(Chapter
9(commencing with Section]000)of Division 3 of the Business and Professions Code) SWIMMENOPOOLELECTRIC Lp� VALUATION
,y
or that he is exempt therefrom and the basis for flue alleged exemption.Any violation of OUTLEfS-SWITCHES-FIXTURES ry
< Section 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of r -`�
❑ t more than five hundred dollars($500). NHW RESIDENTIAL ELHCIR S .FI'. U
m Cl I,asownerofthepmperty,mmyemployenwRhwagesmtheGsolecompenauoa. —SQ,FT.. TYPE CONSTRUCTION
+ y winds the work,and the avumureis not intmdedoroffered forsale(Sec.7044,Business
and Professions Code:The Convector's License Law does oat apply to an owner of
propenywhobuildsofimpmveaderean,and wImdoxx such varlshimselfordamughlois
employees,providedthatsuchimpmveme. =notintendedorofferedforsale.If, OCC.GROUP EU,however,thebuilding orimprovement is sold within oneyear ofcompledon,Ne owner- TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose ofe le.).[1I,as owneroftheproperty,amexclusively conuactingwith licensedcontractors to QTY' PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Sec.7044,Business and Professions Code:)The ConOador's
License Lawdess not apply tounownerofpx arty whobuilds or improves thereon,and PERMIT ISSUANCE
who contrails for such prejecs withawntractoand licensed pursuant to the Co.msecmre ALTER WATER(HA)
License taw. DRAIN Be VENT- FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this mason BACKFLOW PROTECT.DEVICE O TSIDE FEE
Owner Dale - SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
❑ Thereby eBnn Nati have a cerificato of consent m self-insure,or a certificate of SCHOOL TAX Y_N
Worken'Compemetionlnm
Insurance ecmiFied copy Nereof(Sw.3g00,Lab CJ FIXTURES-PER TRAP RECEIPT q
which PARK FEE YN
covers all employee's under this permit. GAS-HA.SYSTEM- INC.4OUTLETS RHCEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK F
❑ Cenif¢d copy is hereby famished. GAS
❑ Certified copy is filed with Ne ciry inspection division. GREASEANDUSTRL WASTE MIERCEPfOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe completed if Ne permit is forone handiest doRms($100) 'SEWER-SANITARY-STORM PA.200FT. ENERGY FEE
oflenJ
I ccnify met the perfomunce of the work for which this pemtit is issued,I shell WATER HEATER W/VENT/ELPCTR
not employ any person in any manner so m to become subject to the Workers' PAID
Compensation Lawsof California. Data WATER SYSTEMTREATING
O z Applicant Data Receipt#
z 0 NOTICE TO APPLICANT':If,after making this Certifucale of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
Hbecome subject to the Worker's Compensmion previsions of the labor Code,you most TOTAL:
7
forthwith comply with such provision or this permit shall be,dmmed resulted. BUILDING HE
R+" Lr
FTI (] CONSTRUCION LENDING AGENCY SEISMIC FEE
z I hereby affrn Nat there is a convection lending agency for the performance of x d V
O the work for which this p.it is issued(Ser.3097,Co.C) TOTAL: ELECTRIC HE
LL Lenders Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this epplicidion and state Net be above information is MECHANICAL FEE
correct,i agree to comply with all city and county ordinances and state laws refiring to PERMIT ISSUANCE
y building co muction.and hereby andofin repmsemaflvesof Niacity to enmrupm Ne
L) z above-mentioned property for inspection psrpreas. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree m save,indemnify and keep harmless Ne City of Cupertino against
liabilities,judgments,costsandexpensee which may in any wayacerue againmsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in co segyL�eof the granting of this permit.
m ' l aPi 2 /I oo 1�I AIR HANDLING UNIT(OVER IO,o00 CPM)
Srgnaturoo�i,ficanommorown �/ Oate EXHAUST HOOD(W/DUCT) PAID �L.JAS y7M
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building oempa.t store or handle hmardous material
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety 11RATING UNIT(OVER 100,000 BTU) TOTAL:3
Code,Section O Ye32(e)7 EJ No VENTILATION FAN(SINGLE RESID)
Will Neepplicant orfumrebuildingoccupantusa equipmcnmrdevi<eswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous air command ams as defined by the Bay Area Air Quality Management PAID D
District? BOILER-COMP(OVER 100,000 BTU) p' Pi V
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read Ne hazardous contends requirements under Chapter 6.95 of the DEC 2 81993
Califmmim Health&Safety Cade,Sectiuna 25505,25533 end 25534.1 understand Net
if the building docs oat currently have u tenant.Nat it is my responsibility tu notify Ne
occupant of the ex,mo mens which most be met prior m issuance of a Certificate of Cy{I I S fF V Vf L'PI I 114W
kA
Owner or authorized agent Date TOTAL: ISSUED BY: V' 5�\
1 OFFICE