25954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUM"
TRI AL PERMIT NO.
IIUII,UING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25954
'I
BUILDING PROJECTIDFNTIFICAION
BUILDING ADDRESS: SANITARY NO. APPLICATIIOON SUBMITTAL DATE
�Tk LOT I'y�
OWNERS NAME: HONE: CO OR'S NAME: ,,//__ LIC NO:
A/zIVS tJly! klG] NIC COM'ROLp
• RCI ECJEN'GINEER LIC NO: A SS: ❑
21�iL ef',;. , AX (2-v07
CONTACT': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEEBLDGELECT PLUMB MF,Cfi
PERMIIISSUANCE ❑
LICENSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OKaffirm that Iherehy affirthat l am licensed under provisionsof0apter 9(commencing wit TOB DFSCRIPION
M�00WE fail force.1af Division 3of 0e Business and Professions Code,and myliccnse is in PANELS �
W failforce.1 affect.
QZ� License Class Lic.N UPT02W AMPS
;i<n•
Data Co..., 201-1000 AMPS
F,'�Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
„
ZOrL 1 l understand my plans shall l>e used a public records. OVER 1000 AMPS
OZ—
SIGNS ELECTRICAL
License]Professional
X0WU OWNER-BUILDER DECLARATION ON SPECIAL CIRCUIT/MISC.
3 LL F 1 hereby affirm that 1 am exempt from to Contractor's License Law for the TEMP.MET OR POLE INST.
m following reason(Section Business and Professions Code:Any city or county
ON; which requires a permit to construct,alter,improve,demolish,or repair any swemm
�o Wa�F prix , t '1. requires the f hpe Lfl g dt¢mem POWER DEVICE
S
W KOO that h J p , t p n f t Contractor,L L (Chapter
p'P'oty 9(c1 unerring ah Saidin.7000)ofDi to I fSheB :nas IP f::i n:Gtde) SWIMMING POOL ELECTRIC ON
W ,� rthat he exempt that f and me basis fthe exemption.Any violation of
FZa�S
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of OUTLE IS.SWITCHES-FIXTURES /p
am anumcthan five hundred dollars($500). NEW RESIDENTIAL ELEGfR SQ.FT. STORE TYPECONSTRUCIION
a: [ILosowncroftheproperty,ormyemployees wit wagessitheirsolecompensauon,
6,32 will Jothework,and the structure is not intended conferral forsale(See 7] ,Business
and Professions Code The Contractors License Law does not apply to an owner of
propcnywhobuild,mimprovcs therenn,and whodoessuch work himselforthat Ns
wnemr,thee.,pmvided prove impmvementhin not earrof empleered the ttle.wam r-
OCC GROUP RIS.UNITS
however,0cavethe ardenofemem issold withinoneyear or imponve for theowner- TOTAL:
builder will have ilia burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
❑ I,as rofthc pmpertYam cxdusively<ontmcting wit licensed cnntmcmrsto FLOOD ZONE APN
construct the protect(Sec.7044,Business and Professions Code:)The Cont tot's
License Law does not apply roan ownerofpmperty who builds or improves thereon,and PERMIT ISSUANCE
who commam&r such projects with a contrac5or(s)licensed pursuannothe.Dorman,.
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1.,it exempt under See B&P C I'ur this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dam RECEIPI'N
• DRAINS-FLOOR.ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have aemificataidemLxm to self-imum.mucartificateofRECHIPTN
WnrkerA Compensation lnsumncemacmificd copy thereof(Sec.3800,Lida CJ which FlXTVR[5-PER TRAP PARK FEE YN
covers all employee's under this pcmtit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT If
Policy n BUILDING DIVISION FEES
Company GAS-EA.SYSTEM.OVER 4(FA) PLANCHECK FEE
❑ Cenificdcopyisherebyfemished.
❑ CenifteJ mpy is filed with to city inspection Division. GREASIONDUSI RL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need no,Is,complemd ifte permit is unions hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
r Ices.)
I cenifyth:nlnthe q:,fmaram,a ofte work for whichthis permit is issued,l shall WATER I[EATER WNENT/ELF,CI'R
not rnv,ky any parson in any masir as m became subject to the Worker, PAID
Compenxmion Lias, fCalifomia. Data WATER SYST,.,M/1'REATING Data Recciptk
ZZ Applicant
NOTICE:TO APPLICANT:IL after making this Certificea of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.Pp. TOTAL:
f/j hecnmembjecno the Workers Compensation provisions of the Labor Coda you men
a ? forthwith comply with such provisions or this permit shall be deemed revokcal. BUILDING FEE
SEISMIC FEE
0. Q CONSTRUCTION'LENDING AGENCY
1 hereby affirm tat there is a concoction lending agency for to performance of
U z ELECTRIC FEE
O to work fur which his pcmtit is ixaud(Sec.Jig),Civ.C.)
Lenders Name
U' F Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEF.
V I certify that 1 have r.d this application and state that the above information is MECHANICAL FEE
comet. I agree to comply with all city and county ordinances and atom laws relining to PERMIT ISSUANCE
F building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCIONTAX
U2 abuvcmemiorrd property for inspection purposes. ALTER OR ADD TO MECH.
'(We)agree in my 'ademnify and ep barmleas the City of Cnpctlmo against
liabilities jodgunim us and expect hick may innnyway accrue ugaimnsaiJCiry AIR HANDLING UNIT(TO 10,000 CFM)
t' t e
ren quer 'c the grmlpngof speouni.
.✓.�L.� AIR HANDLING UNIT(OVER 10,000 CPM)
DJata EXHAUSTHOOD(W/DUC )
reAppl an Contractor
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0100 BTU) Date Receipt#
Will the applicant or future building occupant stare or handle Incurious material HEATING UNIT(OVER IW.(IOU BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Section 25532(a)?
❑Yea ❑No VENTILATION FAN(SINGLE BESIDE
ISSUANCE DA"I'E
Will the applicantorfuturebuildingmeupamuaeequipmentordeviecswhichuit BOILER-COMP(JHP OR 100,000 BTU)
• hmardom air contaminants as defined by tc Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) P4
District?
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT. */w H C
1 Imine tend the hazardous materials requirements nadir Chapter 6.95 of the 0 79
dthCaleldidia,hb&Snfay Coda ave.ns2551lonit 33 sm,rsponsi lundemand that
J) y y
Cf 0c boa I I.,Joel note,,iandy Codeh Sections
tenant,0,255 ism yd 255nsihilun no unityrstand to 93
Ox< upani of the requirements which must be met prier to issuance of a Certificate of V�rChf
ecnp.m y.
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE