25681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ..U.In NG'EEFTTRICAI, PIiRMrr NG.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDBN'TIFICAT ION 25681
11 UILDING/ADDRESS: V/
/ nn ,// c �'/ ,-/- SANITARY NO. APPLICA'DON SUBMITTAL DATE
//V 3 V�yr Q�' r-( d trt � UNITN Y/ f✓I CC] LOT# /L 9 //4�11-3
O ERS NAME: I NR: 1 /-Z — CONTE OR'S NAME: �� LIC NO: N2 CONTROLN
O Q
d' . a' u ' l�u
IR CHITECTfEN EER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: Q.�. ELECTRIC PERMIT hEE BUILDING PERMIT INFO
UG ELECS' PLUMB MECH
PERMIT ISSUAN 0 El o
LICENSED CONTRACTORS DECLARATION A L C R D AL JOB DESCRIPI' N
140.2, Ihereby 7")affiomhuU 3 ofthrscdinss tied professions
Cods,
9nd(commencing with L
�i1 an fullSection
ods and effeDivisiont3 ofthe Business end Rofcssiaw Cade,and myliceweisu U �
<u� faRfnreeaas ertcct.
FZu( License Claes Lic.# 200AMPS
Frn- y Date Connote 201-1000 AMPS
ONZ_ ARCHITECTS DECLARATION 0 1000 SQ.FT.FLOOR AREA $/SQ.FT.
O Z-G I understand my plans shall W used us public records.
r-taJ
E I
LicensM Professional
,Zt)wu OWNER-BUILDER DECLARATION PE CIRCUIT
Rx'OaF 1 herchy of iimm that 1 am exempt from the Contractor's License Law for the
s+I3 tLm followingreason.(section]031.5,Business and Professions Code:Any city or Runty 4FIAP.M RPOM llas .
which requirex a permit m conswct alter,improve,demolish,or mpur any suuctune PO DEVICES
}2 primer its issuance,also requires the applicam forsuch Permitm�le a signed statement
[a KQCOKLL 9(commencing
with Ssecntionla 0e)ofDiivoisnisoonf3thoefthe uecm/s License Law(Chapter
Business and Prefdesions Code) SWIMMING POOL ELECTRIC VALUAT1W_
u)_y onhem M1e is exempuhemfrom and the baxia(or the Wlegcd exemption.Any violamiono OUTLETS-SWITCHES t_ /ate C.;-
�Q Section 7031.5 by any applicant for a pnrnit subjects the applicant toe civil penalt f O
t mote than Eve hundred dollars($500). NBW RESIDENTIAL ELECTR S .FT.
n n❑ I,asowneroftheprogeny.ormyemploymwiNwe mastheirsolewmpcns.lion, Q STORIES 'TYPE CONSTRUCTION
d willdothcwork,and the suuaure is not inteadcdoroffetW forsnle(Sec.7041.Business
and Professions Cole:The Contractors License Law does not apply an an owner of
propertywho lamIdaor improvesdames.,.nd whodoes such workhiwaelfarthroughhis
on employees,providedthat suchimpram
veenu anintimended orw
offerd foele.If, OCC.GROUP R6S.UNITS
however,the building or improvement is sold within one year(If the owner- TOTAL:
builder will have the burden of proving that he did trot build ar imprnve fm purpose of
sole.)
171 111.j2,
propeay,anmxciusively cnntrecting with licensed conwnorsm QTY. PLUMBING PBRMIT FEE F'LOOD'lONE APN
I.
wn the project(Sec.]044,Business and Professions Cash:)The Contractor's
'droeLewdoesnot applytnanownero!property whobuildsaimprovw Merton.end PERMIT ISSUANCE
who contracts fursuch projects with a contractons)licensed pursuanuo the Commnora pL'ITR-DRAIN&VENT-WATER rA
License Lnw. (' ) FEE SUMMARY
❑ /am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE
Y_N
Owner Date—
DRAINSRP.CEIPI'#
-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ Ihereby affirm that l have acenificeteafcomenrtoself-insure,oraienifcatnof RECEIP #
FIXTURES.PER TRAP
oers al Compyee's nlwumncermit.me fiedcopy mhcrtof(Sow.3gW.Lab CJ which PARK PCE Y N_
ere all employee's under this permit GAS-EA.SYSTBM-I INC.4 OUTLETS RECEIPT p
Policy p BUILDING DIyiww FE S
Company GAS-EA.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ Ceoifiedl copy is hereby famished.
❑ Cenifiedcopy is film with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA i r l SOILS FEE
COMPENSATION INSURANCE —
CEns section need not be completed ifthe permit is foram,handball dollars;($100) SEWER-SANTARY-STORM EA.2001,.• m ENERGY HE
orld s.)
I cenify that in the performance ofthe work for which this permit is issued,l shall WATER HEAT. WNF.NT/ELECiRu
nat employ any persons in any mam¢r so as m become subject 10 the WorkersPAID
z Compereationlawsof Califomis. Date WATER SYSTEM/
nppro.nm mu Dom Receiptp
ZC)NOTICETO APPLICANT:IL aper making this Certificate of Exemption,you should NEW RE DENTIAL PLMB. SQ.FT. TOTAL:
to become subject toe the Warker'.Compensation Provisions of the Labor Code,you most
1 forthwith comply with such provisions or this permit shell be deemed revoked. BUH.DI NG FEE
aD CONSTRUCDON LENDING AGENCY SEISMIC FEE
Vz I hereby affirm Bast Nem is a conswdion lending ag.,for the p.f.ce of
O the work for which this permit is issued(See,3097.Civ,CJ TOTAL: ELECTRIC FEE \
Lender's Name
OIeadcls Address Q'IY, MECHANICAL PERMIT FEE PLUMBING FEL'
L) I cenify that I have need this application and into that the above information is
OW. correct. I agree so comply with all city and county ordinances and Stam laws mlatingto PERMIT ISSUANCE MECHANICAL IEE
Vj building constmction,and hereby ardarim representatives ofthiscity menterupon the CONSTRUCTION TAX
U ? above-atemioned property far inspection purlwses. ALTER OR ADD TO MECH.
(We).grow to save,Irulemnify and keep harmless the City of Cupertino.,aims
liabilIties,jw posets,cants and""Passes eshielmayinert way accweageinsteaid City AIR HANDLING UNIT(TO IgWOCFM)
in consequence a wntingoft is i6
/� ) AIR HANDLING UNIT(OVER Igfgo CPM)
.`l ���IIIJJJ 7
Signamm of pplicanVCon .nor D EXHAUST HOOD(W/DUCI)
PAID
HA DOES MATERIALS DISCLOSURE HEATING UNIT(TO IDq(g10 BTU) Date Receipt is
Will the upplicantn fuure building om.pam store or handle hazardous material HEATING UNIT(OVER 100,tXq BTU) TOTAL:
as defined le the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(u)'1
El Yes ❑No VENTILATION PAN(SINGLE RISID)
ch
Will air contaminants s defined
by the
museerm Ainmuality Management
Distinct,
BOILER-COMP(21HP OR IIXI,M)BTU) ISSUANCE DATE
�Disardoux air contaminants w defined by the Bey Area air Quality Management BOILER-COMP OVER 100,000 BTU P A. 9
Dinnct? ( )
❑Yes ❑No NEW RESIDENTIAL MECH SQ.FT, q r�r n
I have read the Instantmaterials requirements under Chapter 6.95 of the OCT %'/ 199 Vq
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand RI that i
if the building dues not currently have.mennm,that it is my responsibility to notify the
occupant of the requirements which must he met Prior to issuance of a Certificate of fs"Y Ur tNUYCti 1
Occupancy. V
Owner or authorized agent Date TOTAL: ISSUED BY: