25249 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BlmT7Nr.-Rct'CT'Rr7A—l. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECILANICN, 5 A (]
9
BUILDING DIVISION - BUILDING PROJECT IDEN'IIFICATIOry 5J X
BUILDINGADDRFSS: SANITARY NO. APPLICATIONSUBMfITALDATE
+'I UNIT# LO'PN
O NETS NAME: PIfONF.: CONTRACTOR'S NAME: LIC NO: N/C CONTROLp
QAF►A►ti 9. P� 1._4
o, a w
ItasatRC1f1TECT/FIdGINFFR: LCNO: ADDRESS: ❑
u e
coNTncl': PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
•Q
y IF4 —I 36.01:1-- PERMIT ISSUANCE BLDG ELECT' PLUMB MECII� � •�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL lOB DESCRIITION
004Z Ihereby affirm that l am licensed under pmvisionsofaaptgr9(commencingwith
4CL) Scitim Tlgla)af Division 3rf the Businesavnd Professions Code,end my license is in PANELS
�j
V� full fnmeand effect.
"Zu1 License Clazs LiuN UP TO]OB AMPS
6;<c. Date Comment, 201-IOW AMPS
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS 5 .Pf. O •A SQ.IW.
02'-M Iundrmmnd myplensshall 6e used us PubiicmcaNs. � � �� �
F rn E'J SIGNS ELECTRICAL
<gz� LittnsW I'rafcssionul
f OWNER-BUILDER DECLARATION SPECIAL CIRCUITWISC.
5OiF I hereby affirm that I am exempt from the Cinnamon's License Law for the
W 31r-m following noon,(Seen..7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. E
°g which requires.permit 1.construct,char,improve,demnlish,or repair any structure l
prior to sex isomnce,ahomilmms me applicant for such pmo crmfile aaigned statement POWER DEVICES
W_<O that he is licensed pursuant to the pmviamns of the Contractors Liamse law(Chapter
e lyo� 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC - VAI Ug'ja�yF
I_ or 7031. oin by
afromand'he
permitsubjfor the tsthedrxemppoo civiny l
ltyon of OUTLETS-SWITCHES-FIXTURES 1 aeo
ZQ Section thn5ve anydreddomfor a Permit subjects iM1e applicwt mecivil penalty of ff..,I���J
q. not mortmanfivchundmdrty.ormyeni). NEW RESIDENTIALELECR S
W 22 ❑ I,the w.k and themepmcimeimyempinded withwegearml.(So. 0,[4.B linen, QFC STORIES 'TYPE CONSTRUCTION
a will do the andthescCmuisnot's License
La do es farml. to ad Business
and Professions Code:Thr improves
the tor'a alwho law aces not apply to an owner of
own
prolpenywho aressucti,ne moffred through his
however,thebu,lding Wthm tech improvementsarenot earofeopletiod for owmaL OCC.OROUP RES.UNITS
however,the building uri en of proem is sold within one year or improve
for the ewer- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
me.).
❑ Lus ownpr project
(S openy,um Business
ss and-rntrncisions C de:)'Me Contmresm QTY, ` . PLUMBING PERMIT FEE FLOOD ZONC APN
Licenseconstruct the project(Sec.omo Bus ss an ywhobuils Code:) ve Contractees
who contracts
apply manownernfpropmywhased puadmpro the meromand PERMIT ISSUANCE
Lice Cro0nas for such projects with acamrnaor(x)licensed pursuant w me Crno-unor'sLeti FEL,SUMMARY
License w, ALTER�DRAIN A VGN'I'�WATER a
❑ I am exempt urufer5ec. ,P ffi P C for this mmm� BACK FLOW PROTECT.DEVICE SIDE F
SANIrIARY Y N
Owner Date DRAINSFLOON;ROOP, N RECHIPTN
WORKMAN COMPENSATION DECLARATION
S If 'AX Y N
❑ Ihetebypentat lhmlhrance or aEcateafcamentta eelf-insu3l as C.)which FIXTURES-PER TRAP RECEIITp
mimm.1 Compensation Insuranceorcenihed copy thereof(Z.3l Lab CJ which _ R ry
ars all employee's under this permit. GAS-EA.SY$TFiM-1 INC 4 LFT RECF.II'I'N
Policy N - BUILDING DI V IS ON FE
Ej Ccy GAS-EA.SYS'I F,M-OVER4(EA) LANCHECK I9
❑ Cenf0ed copy is hereby wish
the furnished. . - '�
❑.cenifed copy iafilW suite the cityInspection diviaion. GRF.ASf?nNDUSTR WASTE LC NG ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifine permit is!crone humba.'Sollats($IN) SEWER-SANITARY-STORM EA.200ET. ENERGY ME
or less.)
I Certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any pemrn in any manner so as m become .hjat to the Workers.' PAID
Compenvtam Lawsof Califraie. Data - WATERSYS'IEMTREAI'ING Date Roeiptp
Z Applicant
z 0. NOTICH'I'0 APPLICANT:If,after making this Cenifictte of Exemption,you should NEW RESIDENTIAL PLMBr SQ.PP. TOTAL:
FV] become subject o the Workers Compensation provisions of the labor Code,you must
� ; frrmwim comply with such provisions or this Permit shall ba deemed raveled. BUILDING ME �
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEIi
I hereby affirm that mem is a construction lending agency for the perfortmntt of
z
V z the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC ME It
Lender's Name
0 U Lenaer'a Address QTY. MFCHANICALPHRMIT FEE PLUMBING I'IiE
I unify,that 1 have mad this application and state met rhe above information is
G>a correct. Iv to comply with all cit and ordinances and state laws mining to PERMITISSUANCE MECHANICAL FEE
Bn'a Pdhe city yon g
bulleingnlioned pmpmI horchyauphection Inrepsso, vae of rM1la Cirymemer uponrico CONSTRUCTION TAX
(•,) z above we)g.pm is.ind inspection purposes. RADD'1'O MECiI.
(we)agra m save,indemnify and keep hermlm the Cityof Cyy:tin
liuhili)icp.judgments,posts vnJ expenses which may In any wayxwrve�n'mat aid t
' IIAN INO UNIT(TO IO,000 CPM)
yue of the granting r'mis permit.
AIRH DLING UNIT(OVER 10,000 CFM)
gnamm of AppliuinUConwamr ,..gEXHAUST HOOD(WNUCT) PAID
I IAZARDOUS MA'ILRIAIS DISCLOSURE HEATING UNIT(TO IOQOW BTU) Data Receipt
Will the applicant or future building occupant store or handle hazardous material
as defined by the CUPertivo Municipal Calc,Chapter 9.12,and the fla.111i art Surety HEATI NO ON I'I'(OVER 100,IXQ)BI'U) 'f T
Cede,Section 25532(a)r L�.
Yes [],No VENTILATION FAN(SINGLE RFSID)
❑
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will air condomtmfuiniums
as building by thenmu equip mem unlit Management PAID
ammrt? ate contaminanu u dented by me Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU!)
pistricf! ,
❑Yes ❑No NEW RE5IDGN'I IAL MIiCI I. SQ,IT. JUN
I have rod the hamNoe.materials requirements under Chapter understand
of the `
California bI Heahh s ,,Safety God,,aSectors.o 25305,2553]and 25534, l ity 1.mmna that
ifinebuildingerasnotearentlyhaveatenant that it is my responsibility 1.notify the Cpr
sxeupant of the resjuimmema which must W met prior m issuance of a Cenificam of e\ V
Occupancy.
Owner or aumaaml agent Date TOTAL: ISSUED BY: