25964 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO8 .r_R2;f1' PERMIT NO.
APPLICATION/PERMIT, PLUMBING-MECHANICAL �5 p C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION J J v 4
RUILDINGADDRESS: T
yq SANITARY NO. APPLICAION SUBMITTAL DATE
ZO .rte 4 Ll UNIT# LOIa
OWN,4ANAAME: c-+ P NE: CONTRACTOR'S NAME: t LIC NO:
A (I 1504c6_9 '(V,/'L S IS B H IO S i 1 6i/040I N/C COMBOL#
RCHITECT/ENGINEER: CICN ADDRESS: ❑
CONTACT: PHONE Q1 Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT "is Cl PERMIT ISSUANCE Cl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby affair that l am licensed under fChe t 9(commencin n JOB DESCRIPTION
WOO
yes psidprenso per eis
mW Section]000)of Division J of the Business and Pmfeasions Cade,and my license is in PANELS
yam{{'',� Lullnse ClonJcfr�{t
FZy) Date Class_Lia#. � UPT02W AMPS
y Q4=y Date Contractor I 201-1000 AMPS SQ.FI'.FLOOR AREA $/SQ.FI'.
ZO,— ARCHITECTS DECLARATION OVER 1000AMPS
O Z_C1 1 understand my plans shall be used as public records.
W SIGNS ELECTRICAL
Licensed Pmmasiaml
�ya'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
dOyU I hereby affirm that 1 am exempt from the Conuacrors License Law for the
sXi13 e,Evs fulloeingreasam.(Section]031.5,Business and Professions Ccdc:Any city orcounty
L. TEMP.METER 00.1gLE INST.
f Q which requires a permit to construct,alter,improve,demolish,ar repair any structure
F.;!(as prior In its issuance.:Jso requires the applicant lot such permit to file a signed statement POWER DEVICES
a7.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aao 9commencin SWIMMING Pool.ELECTRIC
f Bwith Section Division Businem and mva Code) VALUATION
,Zy onhathcisex by,tryre Bland far
bmisfonhects Judcxetnption. civil
of
FZ> Smtion]03 LS Fy any applicant fora permit subjects Ne applicant toacivil penalty of OUTLETS-SWITCHES-FI%TURES
r mart than five hundred dollars(SSW).
�_❑ NEW RFSIDENTIALELECIR _SQ.FT. I RIES TYPE CONSTRUCTION
CF n❑ Laownk,coodaiedirl ty,e is not
fersthe(Scic.compensation, 1 t
ta. will dothmwork,sena the he Cimalsnmimcnense Law
usnot apply for an owner Business \
and Professions CrNca he Contrdmars License Lnw ane..not apply m an owner nr f n <\�
property whobuilJv nrimproves lherenn.unJ who dates such work htmml❑mMoughhis t' l
employees,prnviJW that suchimpmvcmcrosare not inlendedoroffercJ forsak.IL I ) l fir GROUP � RES.UNITS
hmwevcr.Ne building arimprovemenr is wlJ within ane ycarofrnmplgian,nemwner- TOTAL: J
builder will have the burden of proving that he did nes build or impure for purpose of
sale./' QTYPLUMBING PERMIT FLOOD Zone qPN
❑ I,mowner of rte pmpeny,am exclusivelyamtraming with licensed enntracmrsm . � Co
mroad the project(See.]014.Business and Profe ions CWe:)The ContraPERMIT ISSUANCE
ctads
Laicense Lawdacrnot apply it) n ownerofprnpeny who,build,,rimpmves thereon,and
who contracts for such projects with acterracinr(s)licensed pursuant""he Contractor's
ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
License taw.
[:I1 sat exempt under Seo. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE OUTSIDI: :-
SANITARY Y N
Game, —Da.— DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX YN
❑ 1hereby affirm that l have a cenifeme ofconsent to self-insure.or u certificate of FlXTURES-PER TRAP RECEIPT
Worker Cnmpereation l nsumnce ora mnifod copy thereof(Sec.3o Lab C.)which PARK FEC Y N
save.all cmpleyse:wnder his permit. GAS-EA.SYS'1EM.I INC.4 OUTLETS RC #
Policy# BUILDING DIVIVISSION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ccnifeder,yisherebyfumishW.
❑ Certified copy is filed win the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING hili
CER"1'IFICATE OF F,XEMPGON MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE,
(Thiasection ncalonlbecomplemd it lhepennit isforonehundreddallars($100) SEWER-SANT"TARY-STORM EA.20(dT, CNERGY ITE.
os.)
I artifYthat in the perfonnanceof the work far which this permit isissuW,lshall WATER HEATER W/VENT/ELHCfR
not employ any person m any meaner so as to become subji to the Workers PAID
Compensation Lawsof Califomia. Date WATER SYSTE bOREATING Date Receipt
Q Z Applicant
2 � NOTICE TOAPPLICANT:If,after making this CertificateofExemption,you,should
NEWRESIVENTIALPLMB. SO.FT. TOTAL:
.N. bmnmesubjead to the Workers Compensation provisions ofthe Lbar Code,you must BUILDING FEE
� > funhwith comply with.such provisions or this permit shall be deemed revoked.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is n cmnslruction lending agency for the perfomunce of T ELECTRIC IEE
U O the work for which this permit is issued(Sm.3097.Civ.C.)
Leader's Name PLUMBING IEE
D" 't—' lender's Address QTY. MECHANICAL PERMIT FEE
O U 1 certify that I have read this application and state that the aMwe infnrmmum is
W comet.I agree menmply with all city undcounry ordinances ondxmm laws relating to PERMIT ISSUANCEMECHANICAL FEE
F' building construction,and hereby tordwrive represenmtivelcd this city toenterupon the CONSIRUCI'ION TAX
(� Z above-mentioned leaven,far inspection purposes. ALTER OR ADD TO MECII.
Om)agree to save,indemnify and lamp M1arnless the City of Cupertino against
liubilitics,judgmems,cmts andex,memswhich may in any way accrue agalmt said City AIR HANDLING UNIT TO 10,000 CFM)
inconsequence of Ortingof nix permit. 1 /x, pe
Il -}AVVI` AIR HANDLING UNIT(OVER 10,000 CFM)
Slgnam of Applicnnmemracmrr ) Date EXHAUST HOOD(W/DUCr)
v PAID
HAZARDOUS MATERIALS DISCLOSURE HGTING UNIT(TO IOO,IXO BTU) Date Receipt#
WRINeapplicam ter future haddingmcupant spareor handle haaardous material HEATING UNIT(OVER 100.00kil BTU) IUJAL
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Station 25572001 VENTILATION FAN(SINGLE RESID)
❑Yee ❑No ISSUANCE 1 ATE
` Will thea liconl or futurebmina trees t ordevices whichemit BOILER-COMP(3HP OR IW9oo BTU) D
pp d by then 4ea Air P9 A
haxallous air com.minunu m defnW by IM1c Bey Area Air Qualify Management BOILEk-COMP(OVER 100,000 BTU) I�
District?
41 El Y. ❑No NF,WRESIDENTIALMECH. SQ.FT. 'SAN 11 lyyb
I have rend five havrdous materials requimmcnts under Chapter 6.95 of the
C.lifomia Health&Safety Code,Sectiva,25505.25533 and 25574. I understand that �/ `
if the building dues not currently have a tenon6 that it is my responsibility to notify the CITM OI Cur Nv J
nvupont of the requirements which must he met prior to issuance of o Cenlficam of
Occupancy.
Owner or suthom<d.gent Date TOTAL: ISSUED BY:
OFFICE