25217 (2) APPLICANT TO FILL IN INFORMATION WITHIN REO LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO '"ING-RITMICAL PERMrrNO. ^5^17
APPLICATION/PERMIT PLUMBING-MECHANICAL. L L
BUILDING DIVISION SIGN BUILDING PROJECT IDENTIFICATION NUILDING ADDRIiSS: �� r SANITARY NO. APPLICATION SUBMrfTAL DATE
uNTf# Lor# 3
OW SN ^YP C A O S AM': I &�
V-L N/C CONTROL#
• na di r Ll
AR 1- /ENGINEER: LIC NO:` A D E' ❑
CONTACT: PHONB:
QTY. ELECTRIC PERMIT FEE 6UILDING PERMIT'INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTW. JOB DFSCRIPf N
P40Z Iheaday 70000.frmthaU amlicerrmirm.provieionsimas Cote. (it mtnencmg with
�i100O Sce[ion r and I f Division 3 rf the Business and Prrfeseiom Cole.ani my license is in ppryPyS
ttUU full rune ani offer/. -1/I y/G
6z Licena�p �yCs OV Lla.x YaJ UP TO 200 AMPS '
y 6 Dm /1V�J_] Contractor 1„W. 201-1000 AMPS
ZOy� ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA $/SQ.IT.
OZ-0 I understand my plans shall I e used as public records.
�y Licensed Professional SIGNS ELECTRICAL
fid p�Q OWNC•R-BUILDER DECLARATION SPECIALCIRCUIT/MISC. I
S%OaF 1 hereby afftrr that I an exempt from the Connecmr's License Law for the
W 3 0 0 y following mason.(Section 7031.5,Business and Professions Code:Any cityaro unER coty TEMP.MHTOR POLE INST,
which requires a permit to construct,alter,improve,demolish,or repair any structure
nI 7 He, its issuance,alimix,ires lher,dicant farramh impact 1.fits a tMoadminar ant POWER DEVICES
E5
00 that he is licensed pursuant to the provisions of the Contractor's License law(Chapter
adp� 9(comrn1comgwith Section70(N)rf Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefrom oil the basis for the alleged exemption.Any violation of OVfLEI'S SWITCHES-FI%TIIRES #
t,a Section 703 LS by any apan
plict for a .it m subjects the applicant a civil penalty of
an,more Iran It.hundred dollars($5(10).
049 ❑ Luownernftheprpcny,ormyemployeeswithwegeansnhcireolecumpetlamion, NEW RESIDENTIAL EL —SQ,FT. STORIES TYPECONSTRUCTION
a3— will do the work,and theswcmre is amintendedmoffarad forsule(SecJ044,..air..
orad Professions Cale:The Contractoes License Law does not apply to an owner of
proprny who bniide m improves thereon,end who does each work himself or Ihnrgh his
own employees,provided that such impeavemmats a2 not intended or offered for aide.If, I OCC.GROUP RES.UNITS
however,the buildingorimprovement is sold within oneyearofcnmplelion,lheownm- .l.
builder will have the burden of parsing that be did not build in improve for purpose of
sale.).
❑ 1.as owner of impact ,am exclusively contracting with licensed contractors to QPY, PLUMBING PERMIT FEE FLOODZONE APN
construct the prjecl(See.7144,Business and Profrsairns Code:)The Cortrailora
License Law duration apply toad owncrofpropery who builds or improves thereon,and PERMIT ISSUANCE
who contracts forsuch projects with aeonraclonslicensed pussuanttothe Cormactors pLTF:R-DRAIN&VP,NT-WATER(PA) a
License Law. FEE SUMMARY
❑ 1 em exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE .0
SANITARY V N
Owner Delo DRAINS-FLOOR,ROOF,AREA,C ECEIPTp
• WORKMAN COMPENSA'T'ION DECLARATION S I.T Y
❑ Ihertby orffum thatlhuveattnifcale of consemto salt-insure,orettnifca¢of Fl%TORES-PER TRAP RECEIPT'#
Workers'Compensation Insurance m a rectified copy thereof(See,3800,Lab C.)which Y N
traversal?employee's under this'rardt GAS-EA.SYSTEM-1 INC. OUTL 5 RECEIPT#
Policy# IU DING DIVISION PEES
Company
❑ CeniGrd copy is hereby finished. GAS-EA.SYSTTM-0VER 4(EA) .E
❑ Certified copy is Filed with the city inspection division. GREASMNDUSTRL WASTE NTGRCE "A"whiiiii _j
CERTIFICATE OF IDGIMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed iflhe permit is for one hundred dollua(SIM) SEWER-SANITARY-STORM FA.200FT. ENERGY IEE
or less)
Icerify that in the performance of the work for whichnim permit is Issued,I mall WATER HEATER W/VENLILECTR
nes employ my pacions in any manner so as to become subject to the Workers' PAID
Z Gmtpritimom Lowera(Culircrim. Data WATER SYSTRMIGUTATING Data Reeeipt#
Applicant
z�z�-I O NOTICE TO APPLICANT.If,afmr making this Cerifrcaleof Exemption,you should NEW RESIDENTIAL PLMB, SQ.IT TOTAL:
[" r/) become subjeeOo the WOrkers Compensation provisions of Ne Labor Code,you most
FL>!i > forthwilhcomply with tech provisions mthis petition,shall be deamM revoked. BUILDING FEE
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the peAormence of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ ,
Lender's Name PLUMBING FEE
V.
U Lender's Address QTY. MECHANICAL PERMIT FEE
U I certify that I have mad this application and slate that the above information is !+
�" Lt1 correct l agree to comply with all city and county on5inances and state laws relating m PERMIT ISSUANCE MEET IANICALFEE
r'� building consmmliom,rad hereby authonse representatives ofnhis city menterupon the GGNti1RDGDGN TA%
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify and keep harmlrss the City of Cupertino against
liabilitica,'udgments,cosi anVd expense whithtrmy ineny way accrue egunst said Ciry AIR HANDLING UNIT TO 10,0011 CFM)
in cn ncpnf the grynl n s permit. 6-3 a —S 3 AM HANDLING UNIT(OVER RLDM CFM)
Signature of AAAp�pllicadt//CCcnntt!5 Data MHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE IIRATING UNIT(TO 100,000 BTU) Data Receipt#
Willtheapplicant m fmure building occupant sore m handle horrendous material HEATING UNII'(OVER 100,1000 BT'U)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Section 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
Will theapplicumorfumre building occupant usrequipmem ordeviceswhichemil
BOILER-COMP(3HP OR Illfl,(IOO BTU) ISSUANCE DATE
hansom.,an contaminants us defined by the Bay Arte All Withly Managmeom BOILER-COMP(OVER• 100,000 HTU)
Miami? pts �T
❑Yes ❑No NEW RfeSIDENTIAI.MECH. SQ.FT.
I have read the commous materials requirements under Chapter 6.95 of the t��s
Cullfomiali.itb&SafetyCode,Senions25505,25533atid25534. 1undecnamddica F/ �IV�
accupthe wilding docsommentmlyhave atanan mhauirmyresponsibility noonday the C�/y 9.
mcupn a es note are whit ve R o mel poor m issuance of it Cto notify he
PXbe G'3O'73 `
Owner or authorized ager Data T L. ISSUED BY: