25790 (2) APPLICANT TO FILL IN INFORMATION WITHIN HED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIITILYIIN/:-11-EC. RICA], PERMFFNO.
APPLICATION/PERMIT
1'LUMBIFG-MECHAMCAI. C J(�O
BUILDING DIVISION IIUII,DING PROJECTIDEN'TIF'ICA'1'ION J r J
BUILDINGAU CSS: / SANI'IARYNO. APPLICATION SSUBCMITTAL
DATE
OUNI LOl'ro —t UB"�
WN sn CONTR LIC NO: N/C COMROLM
RCHI'l I:C/FNGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11Da' El 0
LICENSED CONTRAM OWS DECLARATION APPLIANCES-RESIDENTIAL HJT
Matz l hereby affirm mat l am livensedunderprovisions ofChnmer 9(commencing with 10H UFSCRIPI'ION
�00 Section 7100pof Division3ofthc Business and Professions Croda,andmylimmelsinPANELS
+l199
full forte and erred.
,Y V UPT0200AMPS
'VE license Class Lic.p
.q6y Data Cluddiddl 201-10X0AMPS
F-yZ ARCHITECTS DECLARATION OVER I"AMPS SQ.IT.FLOOR AREA b/SQ.IT.
��up- IundcmanJ rn,dum,mll be used®public records.
F m F W SIGNS ELEC'T'RICAL
'�{{y�j Licensed Professiem
Eya'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO y V I hereby affirm that 1 am exempt from the Cnmmed, License Law for the
0034{—n following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F�OQ which requires a pernia to construct.alter,improve,demolish,or repair any rmemre
EKY$ prior to its issuance,also oximos the applicant forsuch Permit o Gk a signed statement POWER DEVICES
C¢O that he is licensed pursuant to the provisions of the Commmors License Law(Chapter
a'1o�s, 9(commencing with Section 7")of Division Sof the Business and ProfcssiansGde) SWIMMING POOL ELECTRIC VALUATION
yXj_y or that he is exempt therefrom and the lards for the alleged exemption.Any violation
bof O1'LETS-SWRCIifS-Fl%TURCS
�7< Section 7031.5 by any applicant for a permit subjects the applicant macivil penalty of lf
am more Ilan five hundred dollars($500L
fStS❑ NEW RESIDINTIALELECPR SQ.FT. STORIES TYPE CONS'TRUC'T)ON
Wporo ❑ I,asownernfinepropeny,mmyemployeeawimwagesmmcirsolecomp<rnution,
y will do(lie work,and the structure is not intended orndfered forsale(Sm.9044,Business
and Professions Code:The Convectors License Lew does not apply In an owner of
propeny who builds or improves thereon,and who does such work himself tar through his
empinyeas.pmvideJ lha,such impravetnenlaurenn,inOcnJttloroffcrtdforsnlc.IL OCC GROUPEA"UNITS
however,the buildingorimprovement is sold within one yearofmmpletion.themener-
builder will have the burden of proving that he did not build or improve for purpose of
1
.autwncr of me prnpeny,am cxclusivelY<ontmcling with licensed conlractorsm QTY. PLUMBING PERMIT FEE U'l,
ILOOONli
nvruct the project(Sec.7044,Business and Professions Code:)The Commemra
t cense lawdues not apply to m ownerufpropmy whobulldsm improscsmereon,and PERM1l'ISSl1ANCE
whoclmracts forsuch projects with acdrameor(s)licensed pursuant othe Contractor's ALTER-DRAINA,VENT-WATER(EA) FEE SUMMARY
Liccnsc Law.
❑ 1 am exempt under Sec. .B At P C for this reason BACK FLOW PRO'PECf.DEVICE O TSIDh FEES
SANITARY YN
Owner DatO DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ 1hcrebyoffirm that l have reanificale ofconxnuoscl(-insure,ora ifiameof RECEIPTp
I��Wnrkers'Compensu,ion lnsurenmorec<nifiedcopy Hereof l$ec.38W.Lab C.)wM1ich I iT\ .,'TA iI r PARK FEE YN
mall employee's under this permit. GAS-EA.SYSTEM-I si .40 .EfS RI3CI?IP1'p
Policyk _ l I r l I BUILDING DIVISION FEES
Company '-BA,SYSTGWOYERI� I 1'IANCHECK FEE
[ICenified copy is hereby famished.
C] CenifmJ copy is filed with the city inspcninn Jivixion. GRA STIR CF GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' .GREASE TRAP _. SOILS FEE
COMPENSATION INSURANCE
(This section amid not be completed if me pertnil is!mane hundreddo11ars($10D SEWER-SANITARY-Sl'ORM EA.200FT. ENERGY FEE
or less.)
I certify thus deme perfony manner
torecome subject to issn Workers'
WATER f11iATF.R W/VENT/ELECIR
nen employ any perm in any manner so m to become subject m the Workm' PAID
Umpcn.vahon laws of Califumia. Data WATER SYSTEM/TREATING Date RecciptM
Q z Applicant
zC) NOTICETO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f" iG hccomesubjemoOhe Workers Compemmim provisions or the Labor Code,you must
forthwith comply with such provisions or this pool shdl he deemed invoked. BUILDING FIEF.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
G 1 heron fir thus mem is a convection leaden for the rfomwee of
yu Co.C.) y pc TOTAL: ELECTRIC FlEIE
U0 'he walk forwhich Chic lre^^it ixissuW(Sec.31199, ly.CJ
Lender's Name PLUMBING 17EE
I<ndKs Address QTY. MECHANICAL PERMIT FEE
U 1 certify that I heir,read his application and slate that the above imromtalion is MECHANICAL FEE
correct, lagrtmocomply with ell city and manly mrdinances and su¢hws relating to PERMIT ISSUANCE
building comforeion,and hereby sulboric,representatives ofthis city lu enter upon the CONSTRUCTION TAX
U z abom mentioned property for inspection proposals. ACT ER OR ADD TO MSCIL
(We)agree to save,indemnify and keep harmless the City of Cuperti^u radial
liubiliilcs.judgnrems,earls and expenses wbichntay to any way accrueagainnemd City AIR HANDLING UNIT(TO 10,000 CFM)
quarts
fib granting of`permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
9�
Si mrc paanVContrnctor Date EXHAUST HOOD(W/UNCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Recciplro
Wil ,eapplicanl or future building occupant store or handle hmmdoua malennl HEATING UNIT(OVER 100.000 BTU)
as def nod by me Cupartiro Municipal Code.Chapter 9.12,and me Health and Safety
Code,Seedon 255320^ VENTILATION PAN(SINGLE RCSID)
❑Yes ❑No
ISSUANCE DATE
Will thea licmmrfowrcluddiln and use mrdevices which ami, BOILER-COMP QHP OR 100.010 BTID
PP S by the
Area Air air contaminants as defined by the Bny Area Air Quality Managemem BOILER-COMP(OVER 100,000 BTU)
UISV C13
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.II', <"
1 have read The harmdous materials requirements under Chapter 6.95 of the
Califamtu Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
fife building Joesnol mortality have a lattice,mai it is my responsibility to notify The ��� A
«spam of the matti emems which mus,be met pnor m issuance ed a Certificate of (✓p f7
Occupancy. C&
Owner or aumonrN
ad Date TOTAL; ISSUED B d;A'
OFFICE (�