25359 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOAl Nc-ns.c1OUCA I. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, f�C 17 /N
BUILDING DIVISION m- BUILDINGPRO]KC'1'IDEN"IHICATION G J 3 VM
BUILDING��DD ES$. S�ar�$�� SANITARY NO. APPLICATION SUBMITTAL DATE
2
((JQJQ UNIT# LOT# r'
NBRS NAcMH: PHONE:' CON" OH' A LIC NO:
N/C CONTROL#
6 4++, s 9oB 7J 2-813 9
p RCHITECT/FNGINEHR: LIC NO: ADDRESS: ❑
0 CONTACT: PHONE: ' y.>.a-.. TS "d'? '
Ep QTY ¢• , �ELECfRI PCRMIT, ., I FEE BUILDING PERMIT INFO
n BLDG ELECT gLUL4H MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ihereh ffirm that l am licensed underrovisions mChater9(commencing TOB DESCRIPTION
A02 Yo P p (e eisin
{s]0�B0I� fell to.add of Dtvision3of the Business and Professions Code,and mylicrnuisin PANELS
F�CrU LiceracCliess fwt.
FZµt License Class Lic.p UP T0200 AMPS
rn Q y Dec Cnmmeam 201-1000 AMPS
ZO,Z ARCHITECT'S DECLARATION SQ.FI'.FLOOR AREA $/SQ.PT.
OVER 1000 AMPS
O Z I undersand my plans shell h used as public rwarda.
SIGNS PlECR11CAL
� �� Licensed Professional - r f� B
OWNER BUILDERDECLARATIONthe Ce tra SPECIAL CIRCUIT/MISC.
W 41U 1 ngherebymason.
n.(Se that I am exempt from the Conions rs License law for the
W 3 k ti following reason.(Section]Bl LS.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. I ILS
SFANO; Il its rearapermitmpaim,doe oleicimpravu de .it,,or rep air statement
'}0 thione iaicense puemornto the
thevisios for the Co p.mtors License
La smmm.m POWER DEVICES
dW tY<O Thatmhe isncing with
the)of
fDiisiof the Convectors LIcemelaw(Chapter
ayo1 9(commencing with Section]o08)afDiviaionJofNe Business and Professions Code) SWIMMING POOL ELECTRIC
i� (it hin he is exempt herefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURGS
Z¢ Swtion 7031.5 by any applicam for u permit subjects the applicant to o civil penalty of
rmme than five hundred dollars(S500).
W b n❑ husowncmftheproperty,ormyemployms with wagesmtheirsolecompenmdNEW RESIDEJ'HAL F1ECDi on. —SQ.Ff. STORIES TYPECONS'fRUCTION
W will do the work,und the str.dure is not intended oroffered missile(Sec.]044,Business
and Professions Code:The Companies License Law does not apply to an owner of
pmt dy,whabuildxmimpmves Hereon,endwhodoessuchwurk himaelfortluaughli a
employees,provided that such improvememaarenotimrndedoroffated fm sale.
If. OCC.GROUP RES.UNITS
however,the building or milmovement is cold within nae yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ hes owncrofthe pmpeny,amexdusivelycnnuecting wi@licemadcontmnurs.. QT-Y; PLUMBING PERMIT FEE F!COG ZONE APN -
o cal the project(Sec.7044,Hmimss and Professions Code:)The Convector's PERMIT ISSUANCE
License Lawdocs om apply..an ownerafpropeny who builds or improves thereon and
whocommcbfm such Pmjwtswithecanvac..ge)licensed pursuant la @e Contrvnor's ALTER-DRAW&VENT-WATER(NA) a
License Law. FEL SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE DE SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,ARHA,COND, RECEIPI.0
• WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affimr that l have a certificate ofconsenno self-i ns.re,oracertificateof FIXTGRFS-PER TRAP RECEIPIc#
Workws'Campensatinn lnsummeorseenifieJ copy thereof(Sec.3SIXh Leb CJ which PA RK FEE Y N
covers all employees under this permit. GAS-EA.SYSTEM-IINC.40UTLETS RECEIPT#
Policy# BUILDING DIVISION I-TO
Company GAS-
EA.SYSTEM-OVER4(13A) PLANCHECK FEE❑ Cenilied copy is hereby famished.
❑ Certified copy is filed with the city inspeetion division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASETRAP SOILS FIt-
COMPENSATION INSURANCE
(This asedmi.eednot b,completed if Ne pemtit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY MH
m less.)
I certify that inthe perfomunceofthe work for which Nis pemtit is issued,I.JeR WATER HEATER WNENT4iLECTR
urn employ any person in any manner so as t.become subject to the Workers' PAID
z CompesatianlawsMCalifomia. Date ATERS STEM11REVBNG UeC Rweiptp
Applicant
� 0— NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,youshould NEW RESIDENTIAL PLMF. SQ.FT. TOTAL:
fn become subject to the Worker's Compensation provisions ofthe Labor Code,you must
� ? forthwith comply with such previsions m this pemdl shall be domal mvaked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FRE
.CJ I hereby affirm that is a construction lending agency for He performance of
V Q the work for which this pared,is issued(Ser.31190,Civ.C.) TO A ILL EIXCI'RIC PER
Icndes Name {:
laodm's AddressQT.Y; A i `MECIIANICAI.PCRMIT FEE PLUMBING FEE
U I cenify that I have read this application and state that the above information is d e ' W,
wire,. I......in is with all city sod county ordinanaxend stem?ewe relating.. PERMIT ISSUANCE
MECHANICALFEE
rn building construction,and hereby authorize mpresentrtivesafthisciry roenterupnn the
V y nbove-memioned property for inspection porPose.. ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
�i (We)agree to save,indemnify and keep hunnless the City of Cupertino against
IpdxI11 gree ts,costs end ex hich may in any wayaccme against said City AIRIIANDLINGUNIT(TO Ig000CFM)
17,16. ve thegmmin t.
� /g AIR HANDLING UNIT(OVER I0,000 CPM)
Sir+rre of ApplicarrCnntmcfn1 1/SGP/Damm EXHAUST HOOD(W/DUCry
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO itiod 1BTU) Data Rweipt#
Will the epplicam or future building occupy Ime or handle lateral meeriul HEATING UNIT(OVER IIXI,INIU BTU) TOT
as defined by the Cupertino Municipal Cade,Chapter 9.12.end dm Health and Safety
Code,Section 25532(a)T � � VE TILATION FAN(SINGLE RFSID)
13 Yes &rNo
Will thea applicant orfumm building wed BOILER-COMP(311P OR 100,000 BIT ISSUANCE DATE
pp 8 p.nmuequipmrntordevieeswhichcmit
• hazardous air conmminanu as d load by the Hay Are.Air Quality Managemem BOILER-COMP(OVER 100,000 BTU) n
District? PAID
1:1 Yes No NEW RESIDENTIAL MECH. SQ.PT. " ' D
I have read the hazardous materials requirements under Chapter 6.95 of the JUL as
Caliramia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that IYV 9q
if the bolas tool curtentiy ho tau. the its my responsihifly to nosily the 3
occuP�bo
q menu which lfiu be et prior to issuance o Cenif em of
Decatur Hom
Yr✓ Z
Owner ora @mixed agent am 'TOTAL; ISSUED BY: