25963 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO pH1EH8`�FI]FZTRICA. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25963
BUILDING DIVISION BUILDING PROJECT IDE:N'1'IRCA11ON
BUILDING ADDNhS — `— —� 1 SANITARY NO. APPLICATION
�SUBMITTAL DATE
OWNERS NAME: PHONE: V CONTRACTOR'S NAME: LIC NO: SIC CONTROLp
Z Z-6ZY�o 0-11AL 5-W- (a&7979
IAM RCI IITECr/ENGINEER: LIC NO: ADDRESS:
Z67Y TUCYZ5 R-17 "I s. S �
'om'Acr: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I vQI coIfI� (jq. svc. ZZ7-Z7W BLDG ELECT PLUMB MECH
TZI12,
a— [-L WW PERMIT ISSUANCE }x—t
11 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL � JOB DESCRIPTION
OKZ I booby affmrnthat lam liccnsd undcrprovisionsofChaPter9(commencing with
u1 co Section 7W)ofDivision 3 oftha Business and professions Code.and on,license is I. PANELS
FFLFF fullfofccandcffect. .
FZy( Liccnu Ca= �"2 Lic.x (a&797S UP T0200 AMPS
or<a D:nc Contractor 281-1"AMPS SQ.FT.FLOOR AREA E/SQ.FT.
ZOrNis� ARCHITECTS DECLARATION OVER UX0 AMPS
O Z—0 I understand my plans shall k used m public records.
r,of 9 SIGNS ELECTRICAL nII'ny
<x=Q Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I �"l L.. �� J V
a
Dar OOa 1 ncrelry n.(Se that 1 ton exempt from the C^mons Co License Law for the a V
W 3 c.y followingIthe reason.(Section 7831.5.exempt
fr and Professions Code:Any city at hoary TEMP.METER OR POLE INST. m
which requires n permit to construct,alter,improve,demolish,or repair any structure
g,>Sto its ismance.also the applicant far such 't to file a signedstatement POWER DEVICES
prior rtyuires pp pemm
pjmQO thmM1eislicensedpursuannotheprovisions^frheConvnnor'sLice^ulsw(CTtapar SWIMMING POOL ELECTRIC DATE
40.0 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) DATION,
w^y or that he is exempt theafmm and the basisfar the alleged exemption.Any violation of Of1TLETS-SWITCHES-FIXTURES
t r Q Section]831.5 by any applicant for a permit subjects the applicant to a civil penalty id `
2=G not more than Ever hundred dollaca(SSW). NEW RESIDENTIAL fiLECI'R _SQ Ff. STORIES TYPE CONSTRUCTION
ca F_ El1.mownerofthepmpery.ormyemployeeswithwagesastheirsolecompensadoa,
a3'= will do the work.and the smremra is not imcndedor offered for sale(Sec.]046,Business
and Professions Code:The Contractors License Low docs not apply to to owner of
property who builds m improves thereon,and who does such work hiruli'm through his
ovin employees,provided that such improvements arrant intended oroffered fmsale.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,theohner- TOTAL:
builder will have the burden of proving that he did not build or imprve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD'/,ONE APN
❑ Las hoer project
(Site 7 , xcnesis and P uacti^gwirh l.a:)To,Contractor
mswm he pmjcd(Sec.loan
Business and Professions Cdeq The there n,mad
License l�mwdcesnot apply Loan nwnerolpropeny who builds orimproves thereon,and PERMIT ISSUANCE
who contracts fimarch projects witha<ontrectm(s)licensed pursumtt m the Contractors ALTER-DRAIN&VENT-WATERrA
1.1<c.c Law. f' ) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reran BACK FLOW PROTEDEVICEVICE O
CT. 'SIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
m jitIhereby affirm that l have a certiGcto ofcunum to self-insure.or a certificate of IgXTURFS-PERTRAP RECEIPI'x
Wnrkcre'Compemmioanq ldn�s^ymu^�a�rrtr�a<enl Bed copy theraf(Soe.3800,Lab C.)which PARKFEE Y N
co,elle 3 GAS-FA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVIREMSION FEES
IT a
policyx 7
Compsoy K '1'14 GAS-EA.SYSTEM-OVER 4EA) PIANCHECK FEE
❑ Certified<opy is hereby famished.
Sr Certified copy is filed with the city inspection division. GREASE/INDUSTRI.WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPINSAT'ION INSURANCE
(TTisuctionnednmt completedifNepcmmitisfmonchund dollars(SIW) SEWER-SANITARY-STORM EA.2WFL EbMRGY TLE
or less.)
I canify that i^the performmneeofthe work far which this permit is issud,l shall WATER HEATER W/VENT/IiLECTR
nm employ troy persons in any manner an as to become subject or the Workers' PAID
Compensutlon Lawsof Califomia. Date WATER SYS FEM/1REATING Data Recein Is
Oz Applicant NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Z NOTICE.TO APPLICANT:If.after making this Certificate of Exemption,you should
I-" y become umbjen m the Worker's Compemsution provisions of the Labor Code,you most
a > forthwith comply with such Previsions or this Permit shall be deemed revoked. BUILDING Poli
CQ CONSTRUCTION LENDING AGENCY SEISMIC TEE
1 hereby affirm that is a c^ w
nsction lending agency for the performance of
U Z TOTAL: ELECTRIC FE[
U O tM1r work for which this permit is issued(Sac.709],Civ.CJ
Lender's Name PLUMBING FEE
U' F Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and state that the above information is MECHANICAL HE
D.7 corral Iagrtem comply with all city and county enhances and static laws relating to PERMIT ISSUANCE
hungcnnnmction.wdbaeby authorixc rtprtxntativea o(this city toentaupon the CONSTRUCTION TAX
U Z aMrve-mentioned pmWTty for inxpation purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify ilk eep harmless the y of Cope into egdnm
Ilahilities.pol osis and es - vhiMlina^y st 'd C' AIR HANDLING UNIT(TO IO,IXIp CFM)
comeque^cc of th granting of rs permit.
AIR HANDLING UNIT(OVER I0.tp0 CFM)
Sig^amsof Appficam/Co actor Date E%IIAUSI'1I00D(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEA'T'ING UNIT(TO 100,"BTU) Dote ReceiptN
Will the applicant or future building occupant some or handle harardous material
as defined by the CupertidwMu^ieipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 11%1000 BTU) TO L:
C de.Section 25512(al'I VENTILATION PAN(SINGLE RFSID)
❑Yes ❑No
BOILER-COMP3HP OR IIX1.003 BTIJ) ISSUANCEDAT
Will theepplicanwrfuwrebuildingacupum tauequipmem or Jevims which emit
h card^sea air cnntmmarms as defined by the Bay Anda Air Quality Managemcm BOILER-COMP(OVER 101),"BTU) fps 11T
UiaWcff BjD
❑Yes ❑No NEW RESIDENTIAI.MECH. SQ.Ff. 9
I have read the but doses ani reyuirements under Chapter 6.95 of the ftb^ M 2 _
Califomia Heahh&SafetyCde,Sectio.25505.25533 end 25534. I u^dcmmnd Nn
it the buillmgdnes no,currently have a tonant,that it is myresponsiblliy to notify the
occupant of the requirements which must be met Prior to issuance of o Certificate of
Occupancy,
a
Owner ser milunzed agent Das TOTAL: ISSUED BY'.
OFFICE