25179 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIIPERTIND PLUMBING-MECHANICAL PERMIT NO.
Buamrvc IN IN APPLICATION/PERMIT
BUILDING PROJECT 1DF.N'fIPICATION
BUILDIN`GG ADDRES25179
S: SANITARY NO. APPLICATION SUBMITTAL DATE
OW "uvRT� Q P _�9CONTRAC70R'S NAME: LOTM LIC NO: 6 1,
13
ka
CONTROL#
RCHITECOENGINEER: LIC NO: ADDRESS ❑
�dfxf hQ C� n
CO/N.'' nn PHONE p BUILDING PERMIT INFO
yq/4.'T ,�O MGG ylaaf/
(W
15)85 1 .3958 QTY' ELECTRIC PERMTT FEE
B ECT PLUMB MECH
4O}f Z _ PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION gPPUANCES-RHSIDENT/AL
pyy I hereby affirm that l am licensedunderprovisions of Chapter9(commencing with JOB DESCRIPTION
�ya�100Section
of Division 3 of the Business and Professions Cade,said my license is in ppNBL$
0O�+ ci
QocectudoffseK+``
Fz W en
Licse Class T0
LIC.# UP200AMPS t�
rn]y 'Date C... 2011000 AMPS
Z ARCHITECT'S DECLARATION OVER 1000 AMP SQ.FT.FLOOR AREA $/SQ.FT.
O 2•• I understand my plans shall be used as public records.
r3
LicensedProfrsemnul
SIGNS ELECTRICAL
ya2 p OWNER-BUILDER DECLARATION SPECIAL IRCUIT/t TE
x I hereby affirthat 1 am exempt from the Comment's License Law for the
W 30.yfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
�oQ affirm thin
which requires a permit to construct,alter,improve,demolish,or repair any structure
�'¢�
prior to issuance,also requires the applicant for such Permit mfile asigned smm
reent POWER DEVICES
W A O ro
that he is licensed pursuant to the Previsions of the Contractor's License Law(Chapter
dkoff 9(commencing with Section 71100)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Wy 2 or that he is exempt therefrom and the basis for the alleged exemption.Any violation of V
Q Section 7031.5 by any applicant for a pent@subjects the applicant m acivil penalty of E�W�IDENU�EL�
RES
nm more than five hundred dollars($500).
W-mac .❑ I,aeowneroftheprorpertyarmyemployeeswithwageeas Neirsorlecompenserion, _SQ.PT. STORIES TYPECONSTRUCI'ION
P.13— willdo the work,and thestructureis not intended oroffeant farsale(See.7044,Business
and Professions Code:The Comracmrs License Law does not apply to an owner of
propertywhobuilds mimproveathereon,andwhodoes such work himselforthrough his
employees,providW that each improvementsare notimendedoroffer<d forests.if, OCC.GROUP RES.UNITS
however,the building orimpervemenl is sold within one yemofcompletion,theowner-
builder will have the burden of proving Had he did not build m improve for purpose of
sale.).
❑ Los ownerofthepropeny,ren exclusively contracting with licensedconlnetors to QTY' PLUMBING PERMTT FEE FLOODZONE AM
mestmm the project Be,7(44,Business and Professions Code:)The Contractors
License Lewdoa not apply to an ownerofpo tray who builds or impmvesthereon,and PERMIT ISSUANCE
whocontracts forsuch projects with acontraetor(s)licensed pursuant tu the Comm'Wea
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
- ❑ 1.exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT,DEVICE ___U_U_TS_1D_E_TKhS
OwnerSANITARY Y N
Oaro DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION P�ERIYIEI
Y N
❑ Ihereby affirm that lhave eorOf¢ateofco,,thermerd to sf(Sce.39M.Lm C.)which FIXTURES-PERTRAP RECEIPT#
1 Workers'employsationder this
ified copy Hereof(Sec.3B00,LabCJ which Y N
covers all employee's under permit GAS-EA.SYSTEM-1 INCE(FA)
RECEIPT#
Policy p UILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVE❑ CertifWcopyisherebyfamished.❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WATOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE
(This secti,mmednot becompleted iflhe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT.,
or less.)
I certify Nat in the performances of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to Immae subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTEM/DtEATING Date Reeciptp
C) z Applicant
�7�y1 NOTICE TO APPLICANT:If,after making this Cmfifimte of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject the Worker's Compensation provisions ofthe Gbm Code,you must
�i 7 forthwith comply with such provisions of this pemait shall be deemed revoked. BUILDING FEE
H
per, CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
-^a I hereby affirm that there is a construction lending agency for the performance of
V O the work for which Nis permit is issued Else.3097,Civ.CJ eJ0,JkJ. ELECTRIC FL
IxndeA Name
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBIN
ITaI certify that I have read this application and state that the above information is
Or
correct,I agree to comply with all city and county ordinances and state laws relating 0 PERMIT ISSUANCE MECHA AL FEE
buildingeonstruction,and hereby amhorim represenmtivesofthis city menter upon the
U Z above-mentioned property for imperil.purposes. ALTER OR ADD TO MECH. C S UCTIONT %
�+ (We)agree to save,indemnify and keep harmless the City of Cupertino against
ladilities,jidgmom.costs and ex ss which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in c c of the graining permit.
6 B AIR HANDLING UNIT(OVER 10,0110 CFM)
Signature of Applicam/Contractor Daze EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Uate Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(e)1
ElYes ❑No VENTILATION FAN(SINGLE RESID)
❑
Will the aconta contaminates
s building by the
Area Air Quality Management emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardousDi,opair comaminanrs es defined by the Bay Area Air Quality Management BOILER-COMP(OVER I0L0M BTU)
PAID
11 Yea 11No NEW RESIDENTIAL MECH. SQ.PT.
1 have rind the hazardous materials requirements under Chapter 6.95 of the
Californiaia Health Safety Cade,Sections 25505,25533 and 25534. I understand that �NV
if Ne building does not cumendy have a tenant,that it is my responsibility m notify the
occupant of the requirements which must be met prions Issuance of a Camifiea a of /a'',I, L•r
Occupancy.
lOwner
or audionzed agent Data TOTAL: ISSUED BY: