25046 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO MAL PERMIT NO, 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PeOdRCT IDENTIVICAI ION
BUILDING ADDRESS://�� I 11 ,k �< SANITARY NO. "MICICATION SUBMITTAL DATE
ZZ6 E?(, ` w Pn �f"'�� • ?L UNIT# LOT# •'�/
OLP
WNERS�JA.F �E. � CO CII'OR'$NAMSIV]&,, L� '�
I�� �j#�lr/L �y///.1�1i( �!/ NIC CONTROL#
ARCHITI=,'ENGINBER: LIC NO: ADDR f V '1 L't-O 1 N V l 4�f
CONTACT: PHONE: l- ❑
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE `❑ ❑ - ❑
LICENSEDthatIam
CONTunabrsR'SDF.CLARATION APPLIANCES-RESIDENTIAL JOB DFSCRIPf1ON
POOQWz IherebyaffirmthaG a ofilic Business
cid Professions
Code,
my becing wit ��
a�1O0 Section]000)of Division Jofthe Business and Professions Cade,end my because is in pgNEfs
y�w6 full force and<ff
QFy� Licenx u Lie.# O Z.— 6 UPTO2MAMN
rn y Date Contrutm 201-I"AMPS
zONZ ARCHITECTS DECLARATION OVER IIXp AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O z'-'O 1 understand my plans shall Is,used as public records.
F m F W SIGNS ELECTRICAL r
�i Licensed Rvfessionnl p R
NN OWNER-BUILDER firm
DEC ContraGN SPECIAL CIRCUIT/MISC. N
OyF I hereby afflon than I um exmpt from the Contractors License law for the
I+13 u.ma followingoms. cralmn construct, lot,, and improve,der Professions Code:m rcnycity or county TEMP.METER OR PO1.51NST. s
Iez >J which requires a permit re construct,applicant
improve,h permits file
repair any twnme 4
C �v to pursuant
to the
the ionsofthe Co permit asi ed statement POWER DEVICES
prior y pp amti signed
u� 6p rhos he is licenseddth Sectiorotheprovisionsof the Ce Bashes
License Law(Chapter
a a�' u(cnmmencing with$emimn]Ikq)of UivisionJofthe Business road Professions Cade? SWIMMING POOL CLF.CfRIC 41 a
ALUATION
or that he is exempt therefrom and the husis for the al began exemption.Any violation of OUTLETS-SWITCHES-FI%TURCS
QScOhm7031.5 by nay applicant for a pernat subjects the applicant to a civil penalty of
not more than Ove hundred dollars($SW).p NEW RESIULNTIAI.E?L[CB —SQ.FT.❑ 1,usownernftheproperty,ormyemployeeswithwugesastheirsolecompensadon, STORIES TYPE CONSTRUCTION
a �e will dothe work,andthe structure is not imendedoroffered for sale(Sec.0U44,Business
and Professions Code:The Contmemis License Lew does not apply to an owner of
propertywhmbuildsor improves theratmand whodas curb work himxlforthroughhis
ownem to acs, dad that such ins tsars notimendedoroffered forsale.If, OCC.GROUP RES.UNITS
P Y ptovi provemen
however,Ne have
the
burden of a tentroving
is sold within one yeabuild
or improve
omm,for purpose of
builder will hove the buNen of proving @ht he did not build or improve for purpose of TOTAL:
le.).
❑ 1,asownerofthe prolixity,am exclusively contracting with licemWcontractors m QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
,..net the project(Sec.7(vt Business and Poison.,Codenn
:)The Coectors
Licenselaw deesnetapply toenownerofpropony whobuilds orimproves Nestorma d PERMITISSUANCE
whoconimisforsuchpmjwtswiNeconnnor(s)licenxdpunuaitoreContractors
Lt.law. gL.ppUy GRAIN&VENT-WATER(IA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason 0V1515FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Ihereby affirm that l have a certificate ofcotoent to self-insure,or a certificate of RECEIPT#
FlXTURFS-PER TRAP
Worken'Cmnp<nxtion lmurantt orattnified copy thereat(Sa.3800,Lab C.)which PARK FEE V N
covRECEIPT#
en all employee's under this permit I,ry I p�1Cn�J GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy# W IJ lJ 1 BUILDING DIVISION FEES
Company— - GAS-EA.SYSTEM-OVER 4(FA) PfANCHECK FEE
❑ Cer hied copy is hereby famished.
�Cenifiedcopy is filed with the city inspotion division. GREASEtINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('this section nadma be completed ifthe Permit is forma,hundred dollars($10i SEWER-SANITARY-STORM EA.20l ENERGY FEE
or lai
I cenifytbtt in the pc6cmme.m ffic work for whichmis permit is issued,I mall WATER HEATER W/VENTIMECTR
not employ any person in any manner so us to become subject to the Workers' PAID
Compensaion Lawaof Califomit. Date WATER SYSTLMITREATING Date Receipt#
z Appbicial
z� 0 NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L' LI) becemembjem to the Wmker'a Compensation pmvidana.fthe Labor Coll most
fonhwith comply with such provisions to this permit shell be deemed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Iherehy affirm that there ire construction leadingegrncy for the performance of TOTAL: ELECTRIC FEB
V O the work for which this permit is issued(Sm.3097,Civ.CJ
G's ULender's Nnme
L,ndcr'c Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I certify that I have need this application and state that the above information is MECHANICAL FEE at
context.1 context.lag ram comply with all city and counry ordinances and stem laws relasingto PERMIT ISSUANCE
F-' buildingcon and hereb,ionlawire tepresentativumfthis city to enlerupmn lie CONSTRUCTION TAX
V z above-mF.:.t
y for in t purposes. ALTER OR ADD TO MECH.
(W ind y kap harmless the Ciry of Copcnino against
liabilitictts and pen a ichmayinmywoyaccmeagainstxidCiry AIR HANDLING UNIT(TO 10,000 CFM)
in crosscnd f it.
3 AIR HANDLING UNIT(OVER 10,000 CFM)
Signatu ApplicenVCon r Dean EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE 1 HEATING UNIT(TO UXL"BTU)100 Kq Date Receipt Is
Will the applicant or future building occupant store or handle haaardaus matnisl HEATING UNIT(OVER 100,000 BTU) TOTAL:
us defined by the Cupertino Municipal Cede,Chapter 9.12.and the Health and Safety
Cade,Section 23532(a71 ❑No VENTILATION FAN(SINGLE RFSID)
❑Yea
ISSUANCE DATE
Will theapplicaut orfmumbuiliingoceupant uxequipmentordeviceswhichemit I BOILER-COMP(3HPOR Im,000BTU) !iTaq
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? rs_yy��
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.Ff.
I have mud the Safe,,
Code.
metros rauire5533 under Chapter understand
of the
California Health ithe hay Cudc.materials
orquirement and25534.Ch Iter 6.9 of thehad f
if the building
the
not currentlyhave
mm,nma tl@m it myrespoce,ofet tonotify
an Uf I''V+'ClYlllvy
occupantrequirements w prim
nerorter Occupancy.
Owner nuthorireJ agent Date 710A, ISSUED BY: