25610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO B ..L R CAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL !� [' C•I O
BUILDING DIVISION - -BUILDING PRO.IKCT IDENTIFICATION L J v 1
BUIL DING ADDRESS: ��/]i SANITARY NO. APPLICA'GON SUBMTITAL DATE
903 V7T UNIT# LOTp
OW ERS NAME: PHONE' CONTRACT R'S NAM LIC NO: NIC CONTROL#
0 Go S fr�a� D G.
•ARCHGECT/FNGINE, $ LIC NO: AAWESS:
/ 6ec
.4. 105 C0(- /2
CONTACT: PHONE: QTY'. ' CLECTRIC .RMIT . FEF. , BUILDING PERMIT INFO r
BLDG E ECT PLUMB MECII
PERMIT ISSUANCE i�
0 El
LICENSED CONT OR'3DF.CI.ARATION APPLIANCES-RESIOPNTIAL un�nr�rO
q9Z IM1crehy affirm fast I son CENSEDCO TA11IC pmvisDECL DECLARATION
9(cnmmcncing with 6J�L\nRAa'JOB? r/W"T�T,�'
WOO Section 7000)or Division l i f rbc Business it Professions Cade,and my license is in PANELS
FEW.. Licefull nse
C1deffect. S UPT02MAMPS
<Lp License Clss Lic.#
H<u. Date Coa,,; ne,
FNm ARCHITECT D ARA N 201-10(10 AMPS SQ.FT.L100R AREA E/SQ.FT.
7.0 n OVER 1100 AMPS
OZ,.-0 IunJen ns shall bent es pu icrt r
(:.LLt a SIGNS 1iLEM RICAL
r
nnseJ Pndc —,
OWNER-BUI. ER DECLARATION SPECIAL CIRCUIT/MISC.
XOalU. 1 hereby affirm that I am exempt from the Connector's License Low Fort
W3Om following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.ME, ROR POLE INST.
k�rnJ which requires a permit to construct,alter,improve,demolish,or repair any atmmum
cd YF pnorn,its issamacc also reyaires the applicant fomuch permit to Men signed statement POWER DEVICES
E��0 thin he is licensed pmsuam to the provisions ofthe Contractors License Law(Chapter
d 9(commencin with Section 70W1of Division 3 ofthe Busimesvand Professions Code SWIMMING POOL ELECTRIC
gwi ) 'VAIA 0N
XXIy,-,y
or thindo he 131.5 by tap mmond ttbe busmt subjees theJesemption.Anyl violationat ( —
�3< a,,, mTthan by tiny undmaiicmnfof upemtir subjects the applicant toacivil penalty of OU'TLL•TS-SWITCHES-FIXTURE$ g6oa
nor me than Eve hundred Aollam(55110).
� NEW RESIDENTIAL ELECTR _SQ.Pf.
ym ❑ I,the mi ref @eprnpeny,or myemplueo wagesusale(See compensation, STORIES 'IV PE CONSTRUCTION
3_ will do themiland the nincomhe Cont ivtor intruded.,sLicense
seLa crdJ for s not apply to an owner
of
and Professions Gadr.The Contractor Lic<nse law does not apply to an nwnu of
property who builds or improves thereon,and who does such work himself or through his
employees,misidesl lhmsuch improvements are ammicadedofoffred foraale.If, OCC GROUP EA11
however,the building orimprovemenr is sold within one yearofeempletion,the ownerOW
-
builder will have the handed of proving that he did not build or improve for purpose of
sale.), q' P
❑ I,as owner nfthe property,emexclusively mtmractingwith licensed conmacto to QTY'y`iyPI:UMBING.PERMIT'- 'J..IT
,; I1,00D LONL'
construct the pmjcet(Sec.7043,Business and Professions Cock:)The Contractor's
License Law docs not apply to an owncrcfpropmy who builds or improves thereon,and FERMI"INSSUANCE
whocornrucrs forsuch projects with aconvactor(s)licensed pursuant to do,Contractor's ALTER FEE SUMMARY. .
License Law. (EA)
❑ I em exempt unJcr Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE SIDE.PF.LS
SANITARY YN
OwnerDate DRAINS-FLOOR,PpOOP,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECIARA'TION r 'SCHOOLTAX Y N
coveys
cerfiedcap,doncof(Se,rc,of Lab
which N4'I / \ II �. RECEIPT#
Workcr%Com PY FlXTURES-PER TRAP
pensmian Insurance ma co rherenf(Sec.3g00,Lnb CJ which I :E YN
all employee's under this peovii. GAS-EA.SYSTGM-1 ,4 OUTLETS RECI:B #
Policy# i BUILDING DI ION FEES
Company GAS-EA.SYSTEM-OV. �(GA)� u I _ lLJ I 1 I iECK TF, d
❑ Certified copy is hereby furnished.
❑ Certified copy is Glad with the city inspection divi.cion. GRPASEANDULWA EPTOR 1
IfD
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE
(This section need not be completed lithe Permit is forone hundred dollas(51od) SEWER-SANITARY-STORM E.A.200FT. ENERGY FEE
or less.)
I certify that in the Performance of Ne weak far which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ nay person in any manner so ns to became subject 10 the Worker% PAID
O z Comen
psation Lawsnf California. Date WATER SYSTEM?RESTING Receipt#
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT.
F (A became subject to the Waders Compensation provisions of the Labor Code,you..at IAL.
C
borrowilh comply with such provisions or his permit shall be,deemed invoked. 1 LNGFiE
�#
z CONSTRUCTION LENDING AGENCY SEISMIC FEE O
(hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O Ute work for which this Permit is issued(Set,3097.Civ.C.)
Leaders Numc PLUMBING FEE
O F Lenders Address - QTY" x, + MCCHANICAL FERMI' "L if?PE-�-
U 1 ren fy that 1 have rend this application and stem that the shove dornation ""
correct.(agree mcomply with all city and county ordinoncu and stem lows relining to PERMIT ISSUANCE MECHANICAL. E
buildingeonstruction,and hereby nothorm representatives ofthis city to emerupm the CONSTRU ON TAX
U 'Z aMrvc-mratioocd property for inspection purposes. ALTER OR ADD TO MECII.
We)ugree to save,indemnify and kap harmless rhe City of Cu,x nine against
liabilities.judgments.costs and expensesw 'ch may in any way acweageinst said Cit AIR I IANDLING UNIT 10,010 CFM)
in const c fthe erwtmg.f rte
. /D J AIR HANDLING UNIT(OVER 10,000 CPM) 5
g o c pplicw nnacm ate? EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSUR. HEATING UNIT(TO 10pW BTU) Dae Rceeipp
Will the applicant or future building occupant store or handle hamrdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safety HEATING UNIT(OVER 100,W0 BTU) AI-
Code,Section 25532(x):'
El yes 0 N VENTILATION FAN(SINGLE RPSID)
Will rain co icanmrfurore buildi it by the Bay Area it Quaevices which emit
6OILER.COMPLIHPOR 100,000RTU7 ISS ANCE DATE
rid air rnmaminants ns defined by the Bey Asa Air Quality Management BOILER
100,010 BTU)
Diatnrr7 - P A I D
El Yes Cl No NEW RESfUENTIAI.MECH. SQ.FT.
1 have read the hazardous materials 5505,25 33 under Chapter erst of the OCT
C."Llo m Health N Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my msponsibibly to notify 0te
occupant of the requirements which must be mer prior to issuance of a Certificate
fXcupaicy. • J u
Owner or outbodmJ it,
Date TOTAL: ISSUED BY: R 1
OFFICE