25448 (2) J
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x LDP—NU-n:I.hU I [CAL PERMfr NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 r p p 8
BUILDING DIVISION BUILDING PROJEC I IDENTIFICATION L 'V1 4 4�X
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z_1A lot
a UNI7q LOT# 8/�
O ERS 1,4911. 1'H NE: C ALT R'S NAME: /uq NIC CONTROL p
�ARCfI1TELT/ENGINEER: LIC NO:
1���`/ �U
CONTACT - PHONE: HUILDINOPERMITINPO
QTY, ELECTRIC PERMIT FEE
BLDG ChIiC'1PLUMB MECH
PERMIT ISSUANCE El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
p W 2 I hereby off int that 1 um licensed i ndernowisionn orChapler9(commencing with JOB DESCRIPTION
ittoWo❑ Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
;;U5
V ufull furce and effect -
FZW License Class Liap UP TO 200 AMPS
m6y Dula - Cmitm,mr 201-1000 AMPS SQ.PI'.FLOOR AREA - EISQ.FT.
ZOV,_ ARCHITECTS DECLARATION - OVER high AMPS
OZ^M l understand my plans shall bo used as public records.
Ful SIGNSELEC'IRICAL
F5qmYQ Licensed Professional OWNER-BWLDERDECLARAIION SPECIAL
f"OiU 1 hereby affirm thin 1 am exempt from the Crmmcmrs License law for the 1
W31r.m milowingreunna(9ectinn 9(131.3,Business and Profoesluns CnJe:Any city nr co TEMP.METER( FG,L:1S .
La:o< which inquires a permit to canatruct.eller.imptvve,demolish,or.Wit any snucture
prior to i is issuance,also rumires the applicant for such permit to file a signed statement POWERDEVIC p \
C<0C, that he is licensed pursuant the provisions ofthe Contractor's Lieense Law(Chapter
d 0LL 9(umrmencing with Senior 9010)of Divisinn3of the Business vnA prnfessians Cale? SWIMMING POOL ELECTRIC VALUATION
ty_y or that he iscxempuhertfrain and the basis for lire allegrA exemption.Anyvioletion of
�a Section 9031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
Owl ERS WITCH
$ not more than Tic hundred dollars($5110).
ttrr1^p ❑ I,esowneroDheproNny,nrmyemployees with waiessetheirsolemNEW RESIDENTIAL ELECfR _SQ.FT.mperration, STORIES 'IYPECONSTRUCIION
will do the ami the structure isnot intended mothered fursule(See,7044.Business
.it Professions Code:The Contractor's License Law does not apply In an owner of
property who buildsorimproves thereon,and wbodrms such work hirwirer through his
ownemployces,WovidMatsuchimpmvemenmmnotimendedoroffemdformle.IL OCC.GROUP RES.UNI'T'S
however,the building or improvement is sold within one yearofcnmpletion,the owner.
milder will have the burden of that he did not build or int a for u e of TOTAL.
proving prov p rpos
ale).
❑ I,mownerof Nepropeny,am exclusivelycon0ening with licensed contractors to Qom' PLUMBINGPERMIT, FTG FLOOD ZONE ApN
consumer the project(Sec.7044,Business and Professions Code:)The Comments PERMIT ISSUANCE
License Lawdoes not apply to an ownerofpropeny whnbuilds or innPrnveatheremb unit
who contracts for such projects with acnipmeter(s)Ilaened pursunnttothe Communes pLT1iR-pRA1N&VEN'G WATER G)
License Law. ( FEE SUMMARY
❑ 1 an exempt tinder Sec. ,B&P C for this reason BACK MOW PROTECT.DEVICEOI1151DIa E
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IhereM1y affirm thin lhaveecenifiwin of comm�no selLinsure,ora cenifcain of
Fl%TURFS-PFR TRAP RECHIPJ'#
zo_
Workerti'Compenswion Insurance or acertifiM copy thcrrnf(Sec.3g01,Lab CJ which PARK FEF. Y N
coven all employee's under this pared. GAS-FA.SYSTHM-I INC. OUTLETS RECEIPT'p
Policy# BUILDING DIVISION PGIS
ACom any GAS-FA.SYSTEM OVER 4(EA) PLANCI IIICK FEE
Certified copy is hereby furnished.
❑ riilied copy is fled with rhecilyimpectin idienion. GRIIASE/1NDUS'I'RL WASTE INTERCEPTOR GRADING FEE
'CE
RTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(Thi,wetion need not becnmpeediflhe permitisforonehundreidollats($100) SEWER-SANITARY-STORM EA.20011'. ENERGY ITTE
ar less.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEADER W/VENTELECIR
nor employ any person in any m 1
s as to become subject a the Workers' PAID
7-. CorPensation Lawsof California. DateWATER SYSTEM/IREVTING Dr. Receipt N
Applicant
Z�ZQ NO TICE T'O APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.PI'. TOTAL:
l—' (q become subject to lire Workers Compensation provisions of the Labor Crude,you most
lfila^^^ forthwith morply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
.GJ^ I hereby affirm that is v construction lending agency for the performance of
V Q the work for which this permit is issued(See3097,Civ.C.) TOT ELECTRIC FEE
Da Lender's N",
Lenders Address QTY. MECIIANICALPERMIT FEE PLUMBING FEE
L) 1 certify that 1 have mad this application and state that the above information is
F LTa I agree mcomply with all cilymdcormy ordinou.,itud state lows matingm PERMIT ISSUANCE MECHANICAL FEE
building ornuunion,and hereby euthnriu represcntames of thisnrymrnter upon the
above-in nioljedpropeny for ins mpurpnses. ALTERORADDTOMECIL CONS'IRUC`GON'I'AX
(W uMe fo save,indent y nit keep hvmlen he City f Cu iso against
l,abili' erre,cos n xp swbich may lass ay emen einst sail City AIR IIANpLING UNIT(TO IO,IXNI CFM)
ine mance hfpermil.
AIR HANDLING UNIT(OVER 10,000 CFM)
ignnw pplicantlGmtmcmr Date E%HAUST HGOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Wili the i pplicem or future building ccr.pam store or handle fororn ous mumn.1
as definM by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,11(10 EfU) 'TOTAL:
Calc,Section 25512(a)'1
C3 Ves ❑No VENTILATION PAN TSINGLE RESID)
W ill tbeapplicatrt orfumrc building occupant useequipmenmrdeviceswhicb emit
BOILER-COMP(3HP OR 100,000BTU, ISSUANCE DATE
• hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000[]TO)
District]
❑Yes 0N NEW RESIDENTIAL MECH, SQ.FT.
1 have read the Ia(YC u.materials requim5533 under Chapter 6.95 d the 1
CvliliI have
mail&Safety Cale,Secdore 2 imeiraments under C. imipter e.95 o that AUGv i
if the building does not cureendy have a tenant,that it is my responsibility to notify the
Oceupant of the"t irenrenls which must be met prior to issuance of a Certificate of C111' U
cmpaney. r LL Iwu
Owner or aulhorited agent Dale TOTAL: ISSUED BY:3
OFFICE'