25946 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOL -nLEIFRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C 9 A 6
BUILDING PROJECT IDENTIF'ICA'TION G J f.�
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMTTTALDATE
7 UNIT# LOT# n
OWN' SNeJ PHO E: CONT OR'S NAME: LIC NO: r
Vf SIC COMAOL#
351
RCHI'IbUl GINEER: LIC NO: ADDRESS: ❑
COyTACT: PHONE: QTY. ELECTRIC PERMIT PBUILDING PERMIT INFO
n/�..g rL� • I��� P.
FYi J iUC c/ -/7 BLDQ ELECT PLUMB MOH
PERMIT ISSUANCE ?YET
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
I hereby affirm that l am licensedunder of Ch t 9commencin N OB OPSCRI N
❑CZ Y Provisions spm ( gwi • r n/ _�.yg
ts10W0 Section]gp)of DivisionJof the Bulinus and Profwians Cad and my license is in ppNE15
RUERUE fuliforee mW eRect. Q �� �
Licensee / LIC.N UPTO200AMPS -
w Q a Oate Contrnam 201-11100 AMPS
RCHITE(TS DEC A T SQ.PT.FLOOR AREA S/SQ.FT,
OZ-0OVER Ia10 AMPS
O Z—O I understand my plans shell h uutl u public
r o,t s SIGNS ELECTRICAL
64 Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
qx0 IL
W U I hereby affirm that 1 sen exempt from the Connector's License Law for the
tat iSLi l following reason.(Section 7031.5,Basinw and Professions Code:Any city or county TEMP.MBIEt OR POLE INST
t Ie.4' which requires a permit to<onstmcL alter,improve,demolish,or repair any ewnure
72,E prior1.itsissuame,alsorcquirtetheapplicantforsuchpe.I,tofileasignednmemem POWER DEVICES
pj aJt�O
than he is licensed pursuant to the provisions of the Connectors License Law(Chapter VALUATION
Ly�do�' 9(mmmencing with Section 7")of Division 3nfthe Business and Professions Code) SWIMMING POOL ELE IC /
W_w orthat he is exempt therefrom said the buds forthe alleged exemption.Any violation of OUTLETS-SWITC -FIXTURES ! �Da• �l
6 Section 7031.5 by any applicant for a permit subjects the applicant o a civil peadry of
I moathan fiveihepm dollars(5500). NEWRESIDE LELECTR SQ.PT. STORIES TYPECONSTRUMION
n❑ I.asothe wrk,anhepstruct ofmyemployus wiNwagweuheireole compensation,
a will Bothe work,and e: he Co a ono Contractors
License
a w ail does not apply 0 an.Bulinus _
and Aofcuiobu Cale:The Connectors nd who Lew does not apply u an owner of
propertywho beilreorimproves Hereon,
doessuch warthimselfor through Ns
ownemplo,ecs, not imundedarofferctl
forsele.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one year ofcompletion,theowner- AL S
builder will have the burden of proving that he did not build or improve for purpose of -
I`')' QTY. - PLUMBING PERMIT F• Fti ZONE APN
❑ Les the project
7041.Business
s C de:)sed The C nncmmo License Law
the project(Sec.to an
nerofsa and Professions Code)The Contractor's PERMIT ISSUANCE
Lice nu Lawdoes not apply
enaruwncrofp togs)whobolIdami ttothe Thereon,and
who contacts forsuch projectswiNawntrecmde)littnudpursoenuothe Contractors
License Law, ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
- -❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICEO
SANITARY Y N
Owner Date DRAINS-MOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihertby affint Natlhav<ec<rtifi<ere of comm mulGimurt,ora ttnificme of RECEIPT#
Wmkerx'Compenation lsaumnceoracerified copy Nereof(Sce.3800,Lab C.)which Fl%TU&FS-PER TRAP PARK FEE Y N
covcoidllempfoy � GAS-EA.SYSTEM-IINC.4OUTL4,SF.
RECEIPT#
i
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby with
the W.
❑ Certified copy is filed with the city inspection division. GRFASFJINDUSTRL WASTE INT GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This union need not be completed if Ne permit is forme hundred dollars(SIM) SEWER-SANITARY-ST MFA.?MFT. ENERGY FEE
orless.)
lcertifythatinthe Nffrmunce of Ne kfor which Nispermi sissued, hall WATER HEATER WN /ELECTR
not employ any pc y4nanne o m become s t tvBT PAID
z
Co
a i• WATER SY TING Data Receipt#
Applic t
NOTICE1 CANT:IL storm 8th' ernfcau of Exemption,you should NEW RESID ALPLMB. SQ.FT. TOTAL:
V] becnmesubjea To the Worker's Compensation visions ofthe labor Cole,you must
a 7 forthwith comply with such provisions or this pends shall be,deemed revoked. BUILDING FEE
LSI Q CONSTRUCTION LENDING AGENCY SEISMICFEE
I hereby affirm that them is a construction lending agency for the pifforname of
U O NTOTAL: ELECTRIC FEE
e work for which this permit is issued(Sec.JtNI,Civ.CJ
i
Under',Nome 0 � 12nd.e.er•a Address QTY. MECHANICAL PERMIT FE PLUMBING FEE -
LSaI certify that 1 have read this application and sou that the above intonation is MECHANICAL FEE
CW rrect. l agree to comply with all city and county ordinances and state laws offering to PERMIT ISSUANCE,
In building construction,and hereby nmhodu representatives of this city to enter upon the
U z CONSTRUCTION TAX
above-mentioned property for inspection puryoua. ALTER OR ADD TO MECH.
(We)agrte to save,indemnify huMus the City of Cupertino against
Imbildics,jud en cons and aspen s hmey in any way eecmeegeinst lei City AIR HANDLING UNIT(TO IQ000 CFM)
in cmocyu grx'urgof 1 wIt.
1 AIR HANDLING UNIT(OVER W."CJAIA F
Sign. reof pphc.—.-06 Dite EXHAUST HOOD(W(DUC) PAID
HAZAR MATERIALS DISCLOSURE HEATING ONO(TO IM,"BT Uum - Receipt#
Will theappllcant or future building occupantome or handle haxadous material HEATING UNIT(OVER 100, BTU) T
u retired b,, Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
CWe,Sation25532hd? VENTILATTONFAN(SI LERESID)
❑Yes ❑No
' - ISSUANCE DATE
Will Neepplicantmfumre buiidingmcupant useequiementmdeviceawhichmnit BOILER-COMP(3H&100.00)BTU)
hanrdous air conaminents as dcfitud by the Bey see Air Quality Management BOILER-COMP VER IM."BTU)
District? A
❑Ya ❑No NEW RESID IAL MECH. SQ.IT. I•�
1 have read the haurdous materials rtquirements under Chapter 6.95 of the
C.1ifomla Health&Safety Cade,Sections 23505,25533 erW 25534. I undcrsarM Net ,a�
if the building docs not curremly have a tenant,That it is my responsibility 9..6fy the
m of the rcyuiremems which must be met prim to issuance of s Certificate of
Occupancy.
Owner m molunised egem Data TOTAL: ISSUED BY: is
OFFICE Nv