25082 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPVISION PLUMBING-MECHANICAL PERMIT NO. 25082
BUILDING orv[slory APPLICATION/PERMIT
BUILDING PROJECT 1DENTIFICAT'I(1N
BUILDING ADDRESS:
Z `15� L.I•I > �w n[J y�/b-376o SANITARY NO. A/PP�L—KATION SUBMITTAL DATE
UNIT LOTR ^/ 3
OWNERS NAM& / PHONE: CONTRA OR'S NAME: -TWcnrLICNZ� ••.+ l
J N/C CONTROLM
ARCHITECT/ENGINEER: LICNO: ADDRESS: - r � /�� � ❑
CONTACT: 4VL —'�+�IT..Co'WC
PHONE: BUILDING PERMIT INFO
/' PERMIT FEE�fa�G �D 7 U-73S QTY. ELECTRIC PPERMIT ISSUANCE BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORSDECLARATIONAPPLIANCES-RESIDENTIAL
q 00 Ih7000) fflrrmsion 3hat ofth Bused under and
fisions ions Coder and mmenense is in JOB DESCRIPTION
P-1O0 Sectiorce and of Division Sof the Business and ProPossions Cale.and my license is in PANELS
License Ciro.effect. /� ` I + 'DW—Lk.�,,._
y�V y�j License Class 13 Lic.Y +�S �z�� . UPTO200AMPS ( 'I fig=if/flfl
artd Dare .CT7�3—carom emr 201-IOW AMPS
z EO m� ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA
O z^a 1 understand my plans shall he used as public records.
�m Tal SIGNS ELECTRICAL
Licensed part esstonal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OdU I hereby affirm that 1 am exempt from the Commemr's License Law for the
311.y following reason.(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 stmcture
W Y priono its issuance,alsuruquims the applicant fersuch permit to file a signed statement POWERDE 5
GOC 'hat he is licensed pursuant e the provisions of the Contractors License Law(Chapter
adeLL 9(commencing with Section 7000)of Division 3 of fee Business and Professioa,Code) SWIMMING 00 E VALUATION
W
or, or that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of OUTLETS- WR' PS '1 �1 v
f.Z Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of V V
per] not more than five hundred out].($SW).
o ❑ hasownerofthe property,ormyemployceswithwegesestheirsolecompensmion, NEW RESIDENTIAL ELF.CTR .FT, STORIES TYPE CONSTRUCTION
will do the work,sndthe someumisno[incendedorofferedfarsele(Sm.]044,Business ATE
and Professions Cade:The Contractor's License Law does not apply to an gym r of
property who bu it ds or improves thereon,end who does such work himsel f or through his
Own employees,providedthat such improvements arenotintendedoroffered forsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyeare completion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,as ownerofthe Properly,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Conuactors
License Lawdnesnotapply to an ownerofpropertywho builds or improves thereon,and PERMIT ISSUANCE GO
whommonacts forsuch projects with a crmarmer(s)licensed pursuant to the CortiLicense Law. ALTER-DRAIN&VENT-WATER HDG FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ES
SANITARY Y N
Owner Dare DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTR
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affimtthatlhaveacertifcate of consemmeelf-insure,ora certif¢ate of RECEIPT#
FIXTURCS-PER TRAP
Wnrkers'Compensation Insurance ora ce0ifiedcopy thereoF(See.Jg00,Lab CJ which d0 PARK FEE Y—N
-
covers all employee's under this permit.
GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT*
Policy# AP873-- "41-+ BUILDING DIVISION FEES
1W CerCompsatified
Lax,tiil GAS-EA.SYSTEM-OVER4 EA)
'$Cettitied copy is hereby famished, g�R,j s� �,� ( PLANCHECK FEE
❑ Certified copy is Bled with the city inspection dvision. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
'CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(This section evednot be completed time permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA,2001cT. ENERGY FEE
at less.)
I certify that in the performance of the work for which this permit is issued,l shall WATERHEATERWNENT/ELECTR
not employ any person in any manner so as in become subject to the Workers PAID
Z
Applicant Compensatioa Laws of Califomia. Date WATER SYSTEM/TREATING Date Receip[R
oC, NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
Ile!) become subject 0 the Worker's Compensatioa provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE f��o'r'
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
l v
Z 1 hereby affirm that them is a construction leading agency fo a performance of
U O Ne work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: �� ELECTRIC FEE
LIn Lender's Name
O Lender's Address FE
QTY. MECHANICAL PERMIT FEE PLUMBING E
U 3 O 0
U I cerlify Nat I have read this application and a that the above information is MECHANICAL FCL
Qr correct.I agree 0 comply with allcityand coon rdinanma andatatelaws relating to PERMIT ISSUANCE
to buildingeonstruction,andhereby authorize esenomivescfthis city[center upon the - CONSTRUCTION TAX
U y nbm
ave- entioned property for ma,amio tp us. ALTERORADDTOMECH.
�i (We)agree to save,indemnif it keep harmless the City of Cuperrino against
liabilitles,judgments,costsandsswhichmayinaaya, eccrueegainstsaid City AIR HANDLING UNIT(TO IO,"CFM)
in consequence of the gran' of thsperand.
r� AIR HANDLING UNIT(OVER IO,000 CFM)
Signature of A,hcangConOacmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt is
Will the applicant or future building occupant stare or handle hazardous material ''II
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00sil BTU) TOTAL: SV
Code,Section 25532hd?
11 Yea 9 VENTILATION FAN(SINGLE RFSID)
gI�SSUANCE DATE
Will thea contaminants
as didldia BOILER-COMP(311P OR IW,000 BTU) r A I D
pp goccupan[ueeequipmen[ordevicee whichemit
hazardous air conmminants az defned by the Be,Area Air Quality Management
District? BOILER-COMP(OVER IN,"
❑Yee all. NEW RESIDENTIAL MECH. SQ.FT. M A� 1 7 1993
I have read the hazardous materials 5505,25533 under Chapter understand
of the ,VI„ d e J
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat /.
ifthe building does not currently have a Room,that it is my reepensibilhym nmifyme cify Ur L'urrn"14V
oceupaa(of the tequlrements ied t be met prior to issuance of a Certificate of
Occupancy. r •�, --/7/3 ,
Owner or authonzed agent' Date v C
TOTAL: ISSUED BY: VI �