25797 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO :DING-FITCTNIC PERMIT NO.
APPLICATION/PERMIT PLUMBING.MECHANICAL 2579 n
BUILDING DIVISION BUILDING PROJECT IIIENTIFICATION J J
BUILDING A DRESS: SANITARY NO. APPLICATIONSUBMOTALDAIE
UNIT# LOT#
O NERS CO OR'gNAME: LIC NO:
NIC CONTROL
ARCHITECT tNGINEER: ✓'i- LIC NO: ADDS/ I / �LrN �� �u� ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
LDG ELECT PLUMB MECH
PERMIT ISSUANCE 14W ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OKZ I hereby uffrmtet l am licensed underprovisionsofChapter9(commencing with TOB DESCRIPTION
�+s 00 Section 7")of Division 3 ofthe Business and Professions Code.and my license is in PANELS
6i-,U full fora and l 1 �
Fm
, e 1 —- Lie.p V s UP T0200 AMPS J
to Q Dote Contracmr /s 201 If100 AMPS
,n z ARCHITECTS DECLARATIONSQ.FT.FLOOR AREA $ISQ.IT.
2Oy 1 understand my plans se useas public recor
hall bd blic ds. OVER 10110 AMPS
O Z C q SIGNS ELECTRICAL
6 Y� j Licensed Rofessional a
�yv a'6 OWNER-BUILDER DECLARATION SPECIAL CfRCUIT/MISC.
XO y U 1 hereby off that 1 wn exempt from the Contractor's License law for to
to�+a ti following reason.(Section 7031.5.Business and Profession Code:Any city or county TEMP.METER OR POLE INST.
F.40j which requires a pemtit m construct, demolish,or repair any structure
,W Y 2 prior o its issuance,alsorryuites the applicant for such permit o file a signed statement POWER DEVICES OF
�rLOp shat he is Iteenwd,taxtu tt to the prnviriuns of the C.abamor's License Law(Chapter SWIMMING POOL ELECTRIC
aXo4 9(commencing with Section 70W)of Division 3 ofthe Business and Professions Code) VALUaj
W_m or that he is exempttherefrom and the basis for alleged exemption.Any violation of A (�
FZQ Section]0315 by any apaxnatfor a permit s.bjcc,s,hc applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES 4��
t mom than five hundred dollars($500). NEW R1SfDENT1AL ELECRe _SQ.FT. V
X n❑ 1,asownerofthepropeny.ormyemployeeswithwagesustheirsolecompensadon, STORIES TYPBCONSTRUCTION
ywill dothe work,arta the structure ismainteadedoroffered for sale(Se<J044,Business
and Professions Codc:'The Contractor's License Law dao not apply 10 an owner of
property who bui Ids or improves thereon,and who does such work himselfor through his
ownemployces,pmvided Nat such improvementsarcom immridedoroffered foraale.IL OCC.GROUP RES.UNI'LS
however,the building or improvement is sold within one year of completion,the owner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as ownerofohe property,amexclusivelycomrndidgwit licensedmntrucmrs oo QTY. PLUMBING PERMIT FEE FLOOD ZONE nPN
construct the project(Sec.7044.Business and Professions Code)The Contractor's
License lawdoes not apply m ar.orerofpmosery wh.buildsmimproves thereon,and PERMIT ISSUANCE
who contracts forsuch projects wit a commicmr(s)licensed pursuanvothe Contractor's ALTIiR-DRAIN&VENT-WATER E
License Law. ( A> FEE SUMMARY
❑ lam exempt under Sec. ,B k PC for this reason
BACK FLOW PROTECT.DEVICE: O SID s FEE
SANITARY Y N
Owner Dale RECEIPT#
DRAINS-FLOOR,ROOT.AREA,CONU.
WORKMAN COMPENSATIONDECLARATION
ins ON SCHOOL LAX Y N
❑ ers Co affirm oat I have Insurance
or i tertwf coreseetto py thorol'Sesure,tu,Lab C.)atcofwhich FIXTURES-PER TRAP RECEIPT#
Workers Compensation lnurunce orocenificd copy tarot((Sec.35(MI,Lab C.)which PARK FEE Y R
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECE Pr#
Policy# BUILDING DIVISION FEES
o Pane GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby furnished.
nified copy is fled with to city inspection division. GREA$E/INDU$TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION WSURANCE
(This section need not be,completed ifte permit is fortune hundred dollms($100) SEWER-SANITARY-STORMEi,.200FT. ENERGY FEE
or less.)
I venify that in to pcd..eofthe work for which this Permit is issued.)shall WATER HEATER WIVENT/ELRCfR
not employ any Person in any manner so at to became subject to to Workers' PAID
Comen
psationlawsof Cali¢smis. Date WATER SYSTEMaREATING Dote Rcueipt#
� Z Applicant
� NOTICE TO APPLICANT:IL after making his Cenificam of Exemption,youshould NEW RESIDENTIAL PLMIL SQ.FT. TOTAL
U) hecome subjectmte Wturkcr's Cmmperlse4on previsions of to Labor Code,you must
> forthwith comply with such provisions or this Permit shall be domed revoked. BUILDING FEE �•
CV
0.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm ohm there is a conswction lending agency for to pertotmance of
V O the work for which tisermi t is issued(Sec.3097,Co.C.) TOTAL: ELECTRIC FEE -
p
(L P Lender's N:une PLUMBING FEE
Lenders Address QTY. MECIIANICAL PERMIT FEE
V I certify Out I have read this application and sum that the above information is MECHANICAL FEE
correct I agree to comply with all city and county ordinances and state laws misting to PERMIT ISSUANCE
buildings coon.and h.mbyautome represenutivesoMis enentcrupnnte CONSTRUCUONTAX
U strove- nota dpao,rtyf npec' p ALTERORADDTOMECH.
e)a e m suv are if cep formic, a City of C sminm againvr
)tubi ties,' gments suex which. saywayace gainstsdd City AIR HANDLING UNIT('1010,(00 CFM)
cc of egr gof P<
AIR HANDLING UNIT(OVER 10.000 CPM)
i
marc al Applicant Comrednr Dam EXHAUST HO00(W/DUCI') PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.000 BTU) Dam 'Receipt#
Will the ap C.Pe or time,Mu icipal Code,Cng hapter
9.or handle haruNh andmaterialSafe,,
HEATING UNIT(OVER 100.010 BTU)
as defined by the Cupcnino Municipal Cade,Chapmr 9.12,and the Health and Safety
Code,Section 25532(.)] VENTIL,I]ON FAN(SINGLI'.RFSIOI r+
❑Yes ❑No 'a a•YISS ANCE DATE
Willasegmpmn1mdeviceswh,ehcm,l BOILER-COMPQHPOR 100,108 IFUH
Hazardous air temperaments as definW by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) iVOV `j,37993
District!
[IYes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hierarchalit materials Teyuir25533 under Chapter understand
of the C�/r Vr LUF'CN)IIVI
California Health s Safety Code.Section 25505,2553)end,poroi I undersand tat
Ifthe building doesnmments which must
air ohmo is my responsibilitymminify rhe
occupant of the requirements which must be ma prior to issuance of a Cenificnre of
Occupancy.
Owva or eutorized agent Dau TOTAL: ISSUED BY:
OFFICE