25943 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUICDING-IILLU MICA17— PMMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING DIVISION BUILDING PROJECT IDEN5 /ITIFICATION J LTJ
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
-/n'��3
/VS/ / —Wy' ��� UNIT# I.OTM
O RS NAME PHONE
R: LICO RA OR'SNAME: LIC NO: N/C CONTR01.p
ARCHITI:CDENGINHEC NO: ADDRESS/lalpIV
CONTACT: PHONE:
)/I� QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
l9 v LIX ELECT PLUMB MECH
PERMIT ISSUANCE 11 El ElLICENSEDCONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL.
004ZIhereby effimahetlemlicensed underpmvisidns of Chapta9(commencing adultLOB DESCRIPTION
{200❑ Section a and of Division 3 of the Business and Pmfessionv Code,aM my license is in PANELS
POO fall Sectioralub.fect.
GVW Lot ase cans Lic.g UPT02MAMPS
y Dam �7� Contrncmr 201-1000 AMPS x t
Zp yZ ARCHITECTS DECLARATION _ - '— Qrrr.P O E/SQ.FT.
OVER 1000 AMPS
Oz•-p l understand my plans shall be used m public records. - -- t
SIGNS ELECTRICAL t I� J �j' U -I� E
gQ LicensedProfeuional
OWNHR-BUILDER DECLARATION SPECIALCIRCUMMISC. /1
X5(O a F 1 hereby affirm that I am exempt from the Conuanors License law for the v `'L
tA'30 fallowig nmase..(Section 9o]LS,Business and Professions Code:My city or county TEMP.METER OR POLE MST.
(=`z� i which rccut ..famnattoconrtruct,alter,improve,demolish,orM anyswnum POWER DEVICES
f;!j}� priorto its issumw.Wao require the applicant far such perrtduo fil<esignW aatcmem
W��a�00 that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
0. 9 arnamencin SWIMMING POOL ELECTRIC
ka ( gwithS retro T00dthe Division the
vont Cede) V,Ah)jga'�pN
or that he is exempnhercfmmund the basis for the alleged exemption.Any violation of
�Zf Sectiona ioattmit subjects the applicant xecivil penilry of OUTLETS-$WITGHPS-FI%TURES
ot moroubsto Ovohundreddollars($500).
NEWRESIDENTIALELECTR Kip _SQ.FT.❑ Losowneroftheproperty,army cmployecswiN wogeses theirsolecompensenon, STORIES TYPE CONSTRUCTION
a3� will dotheibrk,endthe mrmwrcmememendese La due.,
raele(Sly 7064, wneroa
and ertywh ons Code:The Connectors License raw docs or apply to an owner of
ownproenywyees,pdvidedtroves Nemon,eWattamessuch wokhreffieed forsidhhis OCC.GROUP RES.UNITS
awn employees,providcdNm such improvemennarcnot imm�dW oroffertd for We.If,
however,the building or improvement is sold within one yearof completion,the owner-
huilder will have the burden of in that he did not build or improve for TOTAL:
prov' g P Purpose m(
le).
❑ I,aaownttof Ne propeny,amexclusivelycmnnecring wiN tic<mWcontmmonto QTY. PLUMBING PERMIT FEE FLOOD LONE APN
constmet the project(Sec.](164,Rosiness uad Profesairns C.de:)The Cmntrammr'e
License lawdmeanmapplym unowneroTociperty whobuildsmrimproveatheremn,and PERMIT ISSUANCE
who contractsforsuch projects with a conwcmr(s)licensed pursumno the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICEouTs-15117 ITO
SANITARY YN
Owner Date RE.CEIPJ'p
DRAINS-FLOOR.ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCI(OOLTAX y
❑ lh'ConaNnrmmi hourveattrsi cenifie conxntNof(See re,o,awni0wte of RECEIPTp
FIXTURES-PER TRAP
Workers'Comloyees tilmumnmora ttrtifiedcopY thereof(Sm.Jg00,lab C.)which PARK FEN. Y N
covers all employee's under this permit. RDC
GAS-EA.SYSI EM. INC.4 OUTLETS
Policy M BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certi6WmpyiaherebyfwnishW.
❑ Ccnified copy is filed wiN Ne city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FRE
COMPENSATION INSURANCE
(This smtion need not becomplcred ifhe Permit is forms hundred dollars(SIM) SEWER-SANITARY-STORM EA.200111'. ENERGY FEE
or Ices.)
I certify than pmfomamm of Ne work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
nee employ anyfcrao in any to bccmnx subject to the Workers' PAID
z
Compensation ICLlifoWATER SYSTF.M/1RPATING Dmc Receipt#
0 APPlicant
NOTICE TO PL NT:rraftaKaleing this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
N become subject o the Workers Comoxnsetimt provisions of the Labor Code,you must ,
forthwith comply with such provisions or this Permit Nall be damW revoked. BUILDING PEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE `
1 hereby from that there is n construction lending agency fm the perf.....f TOTAL: ELECTRIC FEE
L) O the work fm which this permit is issued(Sec.3097,Civ.C.)
bks l.y lander.None s, PLUMBING FEE
Q V lenders Address QTY. MECHANICALPERMIT' FEE
Lkl I certify Nat I have mad this application and sax thin this above information Is
so
L4 rem.l agree to comply with ell city and county ondmm es and same laws relating to PERMIT ISSUANCE MECHANICAL ME
_ Ln building construction,and hereby authodm representatives of Nisciry menter upon the
U 2 above-mentioned property for inspection Purpose.. ALTER OR ADD TO MECIi. CONSTRUCTION TAX
(We)agree to save,indemnify and ka harmless Ne City f Cupccore against
liabilities"I .,costs and x sec hmayinanyway cmeagsn" id City AIR HANDLING UNIT CFO 10.000 CFM)
I.
mnsequ a fthe Frmti it. AIR HANDLING UNIT(OVER!0,000 CFM)
ef
SigyffiiimfA tcrnUCom em EXHAUST HOOD(W/DUCT)
PAID
I IAZARDOUS MATERIALS DISCLOSURE 11F, TINGUNIT(TO IM.N)0BTU) Dox Receipt#
Will the applicant or future building occupant mom or handle hnzallons material
as deft tied by the Cupertino Municipal Code,Chapter 9.12,and the liealth and Safety HEATING UNIT(OVER 100,000 BTU) TOT
Code,Sano.M5J200? VENTILATION FAN(SINGLE RPSID)
EI yes ❑No
Will the applicanterfuture buildingwcup ntuxequipmentmdevice.whichcmit
BOILER-COMP(JlIP OR Iro,WO BTU) ISSUANCE DATE
hazardous air contaminants es defined by the Bay Ama Air Quglily Management BOILER-COMP(OVERR 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECIi. SQ.IT, ph
mr
1 have mad the hodmus mmerials reyuiremrnts under Chapter 6.95 of the 11'"''' V
California I lcalth&Safety Code,Sections 25505,25573 and 25534.I underumd Nm
if the building Jas not currently have a tenant,that it is my mpomibility,in notify the
nccupum of the requircmeme which must he met prior to issuance of a CeniOcam of
Occupancy.
city
uh .
Owner or authorimd egem Dem TOTAL: ISSUED BY:
j OFFICE