25418 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO a n rlsRnn'r nu.
APP LICATION/PERMIT PLUMBING PROJECT
25418
BUILDING DIVISION '.BUILDING PROJECT IDENTIFICATION,'
IMILDING ADDRESS:
^ rn_/''1 a ±: - SAN['PAR1'NO. AITLIGYDON SUBMITTAL DA'IE
011 / w` /moi / s UNIT# LOT
OWNERS NAME: PH S CONTRACTOR'S NAME: LIC NO:
N/C CONTROL
A
111TECT/EN GE : LIC NO: ADDRESS:
CONTACT: PHONE: Q,F*T,•h!,(-,-o'r. " "y' t:c:: ;" .: BUILDING PERMIT INFO
J� •'ELECTRIC PERMIT.•"'.'.'•. - FEE'��„
n- J„?"Y,1y:_.„;. _ncw:P:n -.” Y •c BLDG PLUMB MECH
ELF
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 JOB DESCRIPTION
3mZ l hercbv affirm that l am limmcd underprovisions cf Chapmr9 fcammencingwith l
:00 Sectiou 7006)of Division 3 w dw Business and Professions Code.aM my license is in PANELS
P mF. full fimm and effcn.
tuELiccnx Class Lic.p UP TO 200 AMPS
=y Date Cwmranor 201-11100 AMPS SQ,FT.FLOOR AREA 5/SQ.FT.
CroZ ARCH]PECI-S DECLARATION OVER]IRS)AMPS
I undommo d my plans shall be used as public,,cords.
SIGNS ELECTRICAL
Licensed Professional ! n ••� ^
:x6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I
)�U I hereby afford,ha,I am exempt from the Contractor's License Law for the
puri fallowing reason,(Scotian]031.5.Business and Professions Code:Any city m county TEMP.METER OR POLE INST. _ -
Q which requires a permit m mann n,alma improve,demolish,or repair any structure ! R
-rnJ POWER DEVICES - - -
?T�
do, its ismarrim.also requires theapplicent fmnach prmiuo fileasigned setcmcn,
Had he is licensed pwomm 1.the provisions of the Contractor's License Law(Chapter
=per SWIMMING POOL ELECTRIC [Y ATION
%O 9lcommencing with Sa,ion]t1)0)of Division Sof the Business and Rofessions Coda
or that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
;Z¢ Section 7031.5 by any applicant for a Permit subparts be applican miscivil petulty of OUTLET'S-SWITCHES-Fl%'R1RE5
rethan fve M1unJmd dollars(5500). NEW RESIDENTIAL FLECfR _SQ.PT. STORIES TIDE CONSTRUCTION
es LasownvofNc pro,my.ormyemployeeswifwaguu Neirsolec..pens.....
-3 will he work,and theOntaum isnmimanded moffemd forde(Site.]044,Bmmilow
and Professions Code:The Contractors License Law does not apply to an owner of
pmpenywhw buildsorimprovesdaman,and whodoessuch work himndfor Brough his OCC.GROUPEP_
UNITS
own employees,provided thal.mch improvements we not imended or offered for sale.IL
m
however,the bolding improvement is sold within we yearnfcompledon the owner-
builder
wn TOT LI ,
builder will have the burden of proving that he did not build or improve for purpose f
sale). 1T''' 4 •'t7 fm r.wa �'� 'Vh 1`2?°" ;'''Hy.. FLOODZONEN -
❑ Lwowncrofthc propcnY.am exdusrvdy cwnvaring with lmcnsed conmctom QTYr }-t..gi!, PLUMBING PERMII•I -
construct the project(Sec.]044,Business and Professions Cole:)The Cmntols or's PERMIT ISSUANCE
License Law does not a ppl y to an owner e(proamy who builds mirero
pves themed,and
whocontnctsforsuchprojects with armummuo(s)lirmsedpursuwn to the Contractors ;d,y y ' �4'
License law. ALTER-DRAIN&VENT-WATER(EA) ;a,,>�')�;_ry,lp1 FEES 111,11, ?°•q,{
❑ 1 a n exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE O SID FEES
SANITARY Y N
Or Date RECBIPTa
wne
WORKMAN COMPENSATION DECLARATION D0.AMS-FLOOR,ROOF.AREA.GOND. SCHOOL TAX Y N
❑ "hereby w1mm that l haveacenifce¢of eonsem to self-insum,ora conlficemof RECEIPTa
Workers Com,miralon Insurance or a certified copy therrof(Sce.3900.Lab C.)which FlXTIIRFS-PER TRAP PARK FEE Y N
co RECEIPT a
moors ell employce's under This pcmti,. GAS-EA.SYSTEM-1 INCA OUTLETS BUILDING DIVISION FEES
Policy p
Company GAS-EA.SYSTEM-OVER 4(EA) I'LANCIIECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This laumn need not becomplmcd ifthe perms,is flown,hundred dollars($100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
wr mss.)
I minify that in the Performance of the work for which this permit is issued,l shall WATER HEATER WIVENT/ELECTR
nm employ any person to wry mariner so as an become subject to the Worker% PAID
z An pensation Lawsof Califomia. Date M/T
WATER SYSTEREATTNG Dole Reccipta
) icant
O NOTICE TO APPLICANT:IL after making this Cenifcam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
1 7, hecomesubjeuwthe Workers Compensmion provisions of the Litho,Code,you must BUILDING FEE
forthwith comply with such provisions.,,his permit shall be domed revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affiron lou he.is a Ccomore iwn lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this pemtn is issued(Sm.3097,Civ.CJ - - -
Lenders Name yi' •A= ,', ° PLUMBING FEE
F 1<nacra Address
QTY.�.,bb.M1 .( MECHANICAL PERMITt FEE""n
J V I annify that 1 have read,his application and state Nat the above information is - tY 'E HAx-
[3J cwr pV MECHANICAL FEE
D. lin lagree.comply lummyladhomty tcounty.,.--live of and statelaws
rouniating to PERMIT ISSUANCE
building entionction,ant hereby authmiuu pocaenmtives of this city to emerupon Jm CONSTRUCTION TAX
LI)
above-mentioned propve.bidlnii fy and purposes. ALTER OR ADD TO MECH.
(We)agree tw save,indemnify and keep harmless the Citycn Cupertino against
liabiliti Igmemx,cons end swhich may in any wayattmeageinnsaid City AIR HANDLING UNIT(TO HL"CFM)
xqt c he Fran' Ithls permit.
AIR HANDLING UNIT(OVER 10,08)CFM)
mmof Applicam/Con www Date EXHAD$T HOOD(W/DUCf) PAID
( HEATING UNIT(TO 100."BTU) Date Reccipta
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle hamdous material HEATING UNIT(OVER 100 tq0 BTU)
m defined by the Capitation Municipal Cede,Chapter 9.L',and the Health and Safety
Code,Section25532(x)? VENTILATION FAN(SINGLE REST D)
❑Yes ❑No ISSUANCE DATE
Will theapplicamorfumrc huildingwecupunt use equipment ordeviceswhlch,mit BOILER-COMPUHP OR IW.UDO BTU”
i vdous air commitments as dcfned by the Bay Ana Air Quality Management BOILER-COMP(OVER[00.IXNI BTU) _ /•
ialritl? Y !Y P
❑Ycs ❑No NEW RESIDENTIAL MECH, SQ.F1'.
LCalifomia
have read the haardous mammals requirements under Chapter 6.95 of the AUGf)
Ilcahh&Safely Code.Serious 25505.'_5533 and 25534.1 understand that AUubuilding docs nm currently havea mout,that it is my repom,dolhyto notify the
wn of the imimmmeno which must he met prior m issuance of o Cenifirem of T s,ancy.r or amhorizcd agent Dam TOTAL: ISSUED RI':��1
OFFICE