25231 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPESION - E reRMITNo.
APPLICATION/PERMIT PLUMBING IDENIICAI.
BUILDING DIVISION NUILDING 1'ROJEC'T IDb:N'1'IFICATIrIN 25231
BULDINGADDRFSS:, QO Q.J H as a- SANITARY NO. APPLICATION SUBMITTAL DATE
UNITq LOT
OWNERS N.nAME: `r_�l PHONE: Y�� CONTRACTOR'S NAME: pNO �ll�
, 6&L3 wI OEL C v(� N/C CONTROLp
C Cl CT/EN NEER: IJ21iB ADD ESS I� /� ❑
N4)944
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
gkJ)G ELECT PLUMB MF.CH
PERMITISSUANCE �Ly`tl` El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPION
M=z Ihereby affirtnthat l ran licensed underprovlsions of Chapter9(commencing with
fzdµ1t Senion,and of Division 3m`the Business and Professions Code,and try license is in PANELS
<-Zw Till ent tons,and effect.-. ��.5,.�-�_--� �(J�--
H L� License Class_5�`�Lie,.M UP TO 200 AMPg
E,<N Date Convector 201-(LXX AMPS
,Z�toz ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
Oz-0 undersand my plans shall be uscJ us public recuNs. �w\VIS
1..,,4 F W SIGNS ELECTRICAL
Q as< Littnsed Professional
�t �6 OWNER-BUILDER DECLARATION SPECIAL C[RCUIT/MISC. E
X
kO i U I hereby affirm that I am exempt from the Contractor's License Law for the
W 30.y following Mason,(Section 9031.5,Business and Professions Code:Any city memory TEMP.METER OR POLE INST.
E:NO; which requires a Permit consvun,alter,improve,demolish,or repair any Mature
,W2 prior m its issuance,also requires Be applicant fo...ch permit m file.signed statement POWER DEVICES
,,25<C)❑ then he is licensed parsaanno the Provisions of the Contractors License law(Chapter
ny0-
K 9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA5RfV1
or that he is exempthcrefrom and the bens(anhealle allegedAn 1 t [ /7 ��� �i�
yxj Z,� geAny OUTLETS-SWITCHES-FIXTURES �XJ
f 7 Q Section than by any r doll for a permit subjects the applicant n civil penalty of
ESI] not MOM than rofive hundrederony,lormars SSW). NEW RESIDENTIAL ELECJTR SQ.FT.
x322 ❑ othe wrk.andepsuract,armyemployeawiffered sasafeirsokcompersation. STORIES TYPE CONSTRUCTION
will do the undo he Contom ractor
inLicense awdoforsakpply to an owner
rreas
and Profess ns Code:The Conthemen, n who Law dues not apply to an owner of
own propenysvhoes.prolds mied oices that such improanrmatsa erotihwork himselred fortgh his
own cmployees,pmvidW that suchlmprovemenazrtnotimendedoroffercd[orsalc.If. OCC GROUP RES.UNI3S
however,the building or improvement is sold within one year of completion,the owner-
builder .will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
11Las ownerofthe property,am exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
conenrun the pmjcet(Sen.9044,Business and ProPosslO.s Code:)The Contracto a
License lawdces not apply manownerefpropmy who buildsor improves Nerwn,and PERMIT ISSUANCE
whocrmtructs for such projects with acontracror(s)licensed pursuanaotbe Commerce, ALTERDRAIN&V
- LNT-
License Lew. WATER(FA) FEE SUMMARY
❑ 1 am exempt ander Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dam RECEIPTM
DRAINS-FLOOR.ROOF,ARFA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certifwu efcomsent to self-insure,or a certificate of STORES-PER TRAP RECEIPTp
Fl
Workers'Compenssion lnsaunce oraccnifiedcopy thereof(Sa.3800.Lab C.)which FROPARK FtiE YN
covers all employee's tinder this permit. GAS-EA.SYSTEM-I INC.4 ou n.RTS RECEIPTS
Policy 0 BUILDING DIVISION FEES
Company GAS-EA.SYSTEMOVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGR17ASE'IRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is Forenehwdrcd dollarsSIDE) SEWER-SANITARY-STORM FA.21)l ENERGY FEE
or less.)
I certify that in the wef/arnaace or the work for which this permit is issued,):hall WATER HEATER WIVENT/ELECTR
.at employ any person in any manner so as to become subject to the Workcrs' PAID
Cron,ruatnd"ovsof Celiforia. Use WATER SYSTEMO'REATING Date Romig,#
O z Applicant
z0 NOTICE TO APPLICANT:If.diet making Ws Certificate,of Exemption,you should NEW RESIDENTIAL PLsIB. SQ.FT. TOTAL:
become subject m the Worker's Compensation provisions of the Labor Cade,you must
a > forthwith comply with.sPermit such provisions or this peit shall be deemed revoked. BUILDING FEE
0. F CONSTRUCTION LENDING AGENCY SEISMIC FEE
V Z I hereby affirm drat there is a construction lending agency for the performance of T ELECTRIC FEE
O the wod mi
for which this pert is issued(See.3()99,Civ.C.)
P Lender's Name
Lende/s Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U
U I certify That I have read this application and atm¢that the above information is MECHANICAL FEE
correct.I agree to comply with all city and county ordinances and sure laws relating to PERMIT ISSUANCE.
F" building construction.and hereby authodu representatives ofthis city toenterupon Be CONSTRUCITONTAX
U Z above-memitneA progeny far inspection pe teases. ALTER OR ADD TO MF-CH.
(We,)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities.judgment,awe,and expenses which may in any way accrue against said City AIR HANDLING UNI T LTO 10,000 CFM)r
in consequence of the granting of this pemit.
' � AIR HANDLING UNIT(OVER 10,1100 CFM)
Signstmeof Applie, /Cialmcmr Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,OBO BTU) Date Rcc ptN
Will the applicant or future building mrapant store or handle hazsrdous material HEATING UNIT(OVER 100,000 BTU) TAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ore Health and Safety
Code,Section 25532(a)9 VEN'T'ILATION FAN(SINGLE RESID)
11 Yes ❑No
Will thea applicant or future haildingrccupant useegmpmen t ordevices whichemit BOILER-COMP 0HP OR 100,000[ITO)
VSSjfA
pp
hazardous air cmntamioancs a defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
Miami? H. JUN 21 199
❑Yea ❑Na NEW RESIDENTIAL MECSQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the Clj Y
California Health&Safety Code,Sections 25565,25533 and 8534. l understand that Ut cut tH l fry(1
if the building does not currently have a tenant,that it is my responsibility m notify the
cupant of time nequiremems which mus bo met prior m issuance of a Cenifcate ofcro
owapamey. ' �Mw
Owne—emor rizedagem Date TOTAL: ISSUED BY: `•