25838 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOILDIN -hL AI, PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25838
BUILDING DIVISION BUILDING PROJECT IDENI']FICA]]ON'
µO1 LDINCO� CL/7 401 SANITARY NO. APPLICATION SUBMITTAL DATE
liv UNIT# LOT is Ili`
rLilYN NAME: ZONE: CONTRA R' E: LICN
G p NIC CONTROL#
A IIT vN I.. R: LIC NO: ADDRES C/ ❑
CO PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG E3T PLUMB MECII
PERMIT ISSUANCE ❑
LICENSED CONTRACT ORS DECLARATION APPLIANCES-RESIDENTIAL
Dy,Z I herebyaffinn that l am licensed underprovisions of Chapter9(commencingwith JOB DESCRIPTION
WOO Section]000)of Division 3 of Ne Business and Professions Cade,and my license is in PANELS
WI- full force and effect.
F,Z, License Class Ur. UP 10200 AMPS
m« Dutra Contractor 201-BglO AMPS
Fye ARCHITECTS DECLARATION SQ.Fr.FLOOR AREA A3Q,IT.
ZOti l understand my planssh.lI he used as public records. GVfiR 1000 AMPS
OZ—O
F y W SIGNS ELECTRICAL
Q Y j Licensed Professional
wp,d'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUI'17MISC.
XI hereby affirm that I am exempt from the Contractors License Law for the a e 1
tL3ay following marine.(Smiled 70315,Business and Professions CWe:Any city or county TEMP.METER OR POLE.INr o�
F-a'O which requires a permit to concoct,alter,improve,demolish,or repair any smuctare
5tyrnjY� prior to its issuance,also requires the applicant for verb permiva file a signed atatemem POWER DEVICES
,=<O that he is lo,triclminvoontmthe provisions.fine Cannoneer',License Law(Chapter ER I
C.XOK 9(coammenciag with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECT RIC VALUATION
Ea Mott or that he is exempt therefrom and the basis forte alleged exemption.Any violationof
F•Za Section?031.5 by any appllcamfor apermit subjects the applicant toacivil penalty of OUTLETS-SWITCHES-FIXTLETATE
5_� not more.M1nn five hundred dollars G50)). NEW RFSIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
CF_o ❑ 1. sownaoftheprnpeny,ormyemployecswithwagcsotheirsolecompensutioa,
a3e—` willdo the work,and the structure is not intembaloreffered forsale(Sm 7014,Business
and Professions Code:The Cootrdmors License Law does not apply in an owner of
own mrywhobuildsor improve,pro suchcramr,mat Meadow mproveents...marideder.fered hnmgh his CIC ZS.UNITS
employees provided Natsuch improvementsdow n..r1bw k orofferedfoon h If.
maomer,.he building or improvement is sold withinone yeariefcampledon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of r
sola).
❑ I,mownerofthepmpery,umexclusivelyconuactingwimlicened nvcmrsm QTY. PLUMBING PERMIT FEE Il.00D ZONE npN
construet the project(See.7014,Business and Professions Corky The Committees
License Lawdons not apply manowner.fpropertywho build,m improves.hereon,and PERMIT ISSUANCE
whoc.nract,forsucbpon., air u roommel r(s)Iienexedpufsuam to.he Comment, AL'TBR-DRAIN&VENT-WATERFA
License Law, f > FEE SUMMARY
❑ 1 ren c.,.pt under Sm. .B&P C for this mason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECIARATION SCHOOL TAX Y N
❑ I heabyaffmnn that l have ucMificam ofcoascnt to sdf-insum.oracenifmcateof FIXTURES-PER TRAP RECF,IPTM
�Werons Conepcnsatiun Insurance or acenified copy thereof(Sm.3800,Lab C.)which PARK FEF, Y N
covers all employee's under this permit. GAS-EA.SYSTHM-1 INC.4 OU'T'LET S RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cerlifed copy is hereby fumishod.
❑ CeniliW copy is tiled with the Gary iopecnor division GREA$E/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP AP SOILS FEE
COMPENSATION INSURANCE
(This sermon need not be<omple�d�r.he pcmnit is for one hundreid.I1ars($100) I , ANITAHY-STORM EA.2fNIFf. i1 ENERGY FEE
.r ass.)
I anify that in the performance of the work for which.his Parent isissued.l shall ATER HEATER WIVPM/ELECIR
not employ any person to an,manner as.o hcomc subject m the Workers PAID
Gmmpensmlon L.awsof Calif.mia. Date eo WATER SYSTf;MOREA1'ING Data Receipt#
0 z Applicant
0 NOTICE TO APPLICANT:If,after making this Cenificam.f Exemption,you should NEW RESIDINf1AL PIAB. SQ.IT. TOTAL:
rbecome subject to Workers Compensation provisions of the Labor Code,you must
ta^ tt> Forthwith comply with such novinio.,me loo pem aI xhall M deemed revoked. BUILDING PEE
W (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
F" Z I hcrcby offmrmihatthere is a coarvrmtion lending agency forte performance of
U Q thework for which this permit is issued(Sua 3097.Civ.C.) T ELECTRIC FEE
Landers Name PLUMBING FEE
V-' F Lenders Address QTY. MECHANICAL PERMIT FEE
0 U 1 anify that 1 have read this application and state that the above information is MECHANICAL PTi17
>4 LII correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
I-' � building conswction and hereby mabove mprsentatives ofthis city manner upon flee CONSTRUCTION TAX
(� 'z ;Iiabilide1j.d
ve-mormared ray for ins ALTER OR ADD TO MECII.
(M')ogre .ave,ivden mless the Ciry of Cucenin.egmast
m .s cots. p coy way dcarucageins.said City AIR HANDLING UNIT(TO IO,WRCI'M)
in onaqu the /N
-`/ AIR HANDLING UNIT(OVER IU.01X1 CFM)
;definux!
net dAppliwn entrxcmf Dna F,XI COST I IOOD(W/DUCr) PAID
A"BOGUS MATERIALS DISCLOSURE HEATING UNIT CY 101,003 BTU)
Date Receipt p
applicant or future building occupant s.nrc or handle hmerdoe.v material 1BjATING UNIT'(OVER IBO,oW RTU) TOTAL:
by the Cupertino Municipal Code,Chapter 9.12,oul dw Health and Safety
Code,Section 25532rU
icant.rfuwrcbuildingwcupdntuaequipment nrdeviceswh'¢h emit -NILATION FAN(SINGLE RFSID)
❑Yes ❑No THP OR 100,000 RTU
) #rR M
LANCE DATE
� 'WillheapplBOILER-COMP(3
h¢arbmx,air c.ntarnman6 as definN by Ne Bay Area An Quality Managemrnt BOILER-COME(OVER 103,)00 B'I U) {� 3 199
Cia�et, ❑YDEC J
Q o ❑No NEW RESIDENTIAL MECH. SQ.Ff. J
I have sad the havMous materials rwufamcnts ander Chapter 6.95 of the "y Ur uuYCtl1114
Califnmia Health&Safety Code.Sections 25505,25533 and 25534.I understand that s"
f Ne building docs nm currently have a Kamer,third is my responsibility to notify the
e aecupani of the requirements which must be met Prior to issuance of a Cenifmcate of
x upaci
Owner o r authoris.J agent Date TOTAL: ISSUED BY:
OFFICE