25353 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •' PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION F7777pU PROJECT IDENTIFICATION 25353
BUILDING ADDRESS: SANHARYNO. APPLICA'110N SUBM]T1 Pd,DATE
W#•y
UNIT# LOT#
OWNERSNq E: PHONE: CONTRACTOR'S NAME: LI NO:
f f t N/C CONTROL a
ARCIIIIECf(IiNGINE R: LIC NO: ADDRESS: Ml ❑
'UNTACI': PxONE: BUILDING PERMIT INFO
Od) 996 - 7090 QTY. ELECTRIC PERMIT FEE ELECT PLUMB MECH
SKI PERMIT ISSUANCE 0 ❑
LICE NSEII COM'RACTOR'S DECLARA'ION APPLIANCES-RESIDENTIAL
cwz I hereby affirm that l am licensed underpmvisionsof Chapter9(commencingwlth JOB DESCRIPTION
WOO -Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
�ZU full lnse Clad effect.
QFzy) License Class Lic.p IIP TO 20AMPS \`/V.
m 4 y Date Co.,mttor OVER
I WO AMPS I
ZOD S P FL OR $/S .FT.
'— NCHITECI'SDIpCLARATION OVER IWOAMPS
oo I undersand my plan shall be uxd u public records.
O Z F W SIGNS ELECTRICAL
='CQ Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ` ® M p U
ti4x+S,O yF I hereby affirm that I um exempt from the Contractor's License Law for the
W 3 w following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
11='5< which requims a permit m coastruut,alma improve,demolish,or repair any suucam DATE
�W';; prior to its issuance,also requires the applicant for such permit file a signed statement POWER DEVICES
,W<O that he is licensed pursuant o the provisions of the Contractors Licence Law(Chapter SWIMMING POOL ELECTRIC
d X. 9(cnmmencing with Section 7000)a(Division Jofthe Business and Professions Code) VALUATION
or that he is exempt hercfrom and the basis for the alleged exemption.Any violation of 1 ^ r�
Y Section 7031.56applicantfore t subjects the applicant mecivil penalty of OI1lT.ETS-SWITCHES-FIXTURES l L
F Z_G >e any edpermit j
not more than free hundred dollars(SSW).
��O NEW RESIDENTIAL ELECTR —SQ.FT. STORIES TYPE CONS'BIICTION
a_Lo ❑ othe wrk,aOhepeopeny,ormyemployed orro wredfor theide(See compensation,
3� will dothework,amds: he Commemanot idmndcde Law does a,aapply 7044.Rosiness
and Professions Calc:The Conuaamr's License Law ices clot apply If an owner of
is
property who
s.proviid thalasthingimom musem not ch imwork IJmsdfor throughhis
own employees.provided thmsuchimprovemrnaarc notimendedoroffertdforsale.If. OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL
builder will have the burden orproving that he did rmt build or improve for purpose of
vale).. QTY. PLUMBING PERMIT FEE Fl,OOD ZONL
0 [, nproperty.I,es rol'Ihc pperly,am exclusively contracting with mrsm "Nlicensed comcm
constrict me
projeci(Sec.704L Business and Professions Code:)The Contractor's
License Law does not apply loan ownernfproperty whabuildscrimprovesthetmn•and PERMIT ISSUANCE
who romfacts forsuch projects with a contractor(s)licensed put sueduo the cinameners
License law. ALTER-DRAIN&VENT-WATER ILA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEIS
SANITARY YN
Owner Date RECEIPT#
COND
AREA,, .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOLTAX Y N
❑ Thereby affirm thatlhave acenificam of consem to self-insure.oracenifioam of FTKTURES-PER TRAP RCCF,11"1'#
Workers employee.ionler thisermit, ificd copy therm((Sec.3gW,Lab CJ which PARK FEE Y N
co�aas all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS k[CEIPT p
Polwy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenilisdeopykhembyfumished.
❑ Cenifedcopy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FARE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is farone hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the pertonrance of the work for which this permit is issued,)shill WATER HEATER W/VENT/F.LECI'R
net employ any person in any maeco became as m subject to the Worker PAID
z Compensetiomlawzof Califomia. Date WATER SYS IIMOBEATING Date Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT, TOTAL:
G becomesubjecto Ne Wor4er's Compensation provisicnx.fth,labor Code,you must
a > fnnM1wiN campy with such provisions onhia#emit shall be decmW invoked. BUILDING FEEUj
a (] CONSTRUCE,
NON LENDING AGENCY SEISMIC FE
rte- Z 1 hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC IEE
U Q Ne work for which his permit is issued(Site 3097.Civ.C.)
Leaders Name
U"' F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 evoily that 1 have read Nis application and nam that the above information is MECHANICAL Flil?
coned. lagr«mcdmply with allay etd many ordinances and stem laws mlatingm PERMIT ISSUANCE
F" 0 building construction.and hereby authorize represcnativeso(this city to enter upon the CONSTRUCIONTAX
U z above-memianed property for inspection purpases. ALT ER OR ADDTU MECH.
(We)agree to save,indemnify and keep board.the City of CLper im against
liabilities,pohcounts,vests..it x,ms which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
in ggg of the granting nof/this#email.
/1 QQ /Sg /r /�2 )� � AIR HANDLING
HOOD UNIT(OVER IO,OW CFM)
�1 1hd./Apel 4/{/ / /
Signa fApplianVCnmm mr Cr Dam E%HAUS'I'IIOOD(WNUCI} PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hexoardins material HEATING UNIT(OVER 100,000 BTU) TOTAL
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cola,Section 25532(x)? VEMITLAT[ON FAN(SINGLE RES ID)
❑Yes ❑Na
ISSUANCE D7KTE
Will WeappllcunmrfmurebuilJingoacupnnt use equipmcntdr Jcviceswhichemit BOILER-COMP(311P OR 100,000 BTU)
�hararmir,air commandants as defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER 100.000 RTU)
District?d ❑ y Yes ❑No 2 NEW RESIUENTIAI,MECiI. SQ.FT. � 171
1 have real the hazardous medials 5505,25533 under 34, 1 un erst of the Jilt �•7 l
if the building
ingthrdoes
not currently
Sections 25505,25533 and responsibility
1undersand that �/ #j
if of gdoequirem nts which must be
itismy reuarame ofa Ce ificat the ( 99
occupant of the requirements which t be met prior m issuance of a Cenific to of C/I
oacap'�") 7 1.],T�9.f .._I UALI Hr
Owner/or/umbar. lager Date TOTAL: ISSUED BY: •J
OFFICF