25048 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDL .-LL. 1'N AL PF:RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25048
BUILDING PROJEC1' DFINTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
C I-
F// UNITM LOTM
SNAML: PHON^ s co �SC T)R'S NAM':/ s LIC NO:
l -� ` I•/9116 NIC CONTROL#
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ARCff1TECT/fifJGINP.f?R: , ICNtr ADDRESS* O r
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CONTACT: HONE: /
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLIX3 ELECT' PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
O=Z Ihereby affirm that l am licensed underprovisinnsofCAaprer9(commencing with JOB DESCRIPTION
Poo Section 7000)of Division 3 of Ne Business and Professions Code,and my license is in PANELS
,do fall farce and effect.
f W License Class Lic.# UP TO 200 AMPS
m<an Date Contractor 201-IWOAMPS
H z ARCHITECTS DECLARATION SQ. .FLOOR RBA $/SQ.FT.
Z ),�= OVER BOB AMPS
OZ-"p Iuw
nderenJ my Tincts shell be used ea public records.
FW SIGNS ELECTRICAL )
License)Professional OWNER-BUILDER DECLARATION SPCCJAI.CIRCUIT/MI$ ,� t@n I (-•
DCCRa�OaU I hereby affirm that 1 am exempt from the Contmemr's License law far the
al a following Mason,(Section'/0)1.5,Business and Professions Code:Any city mcounty TEMRMLr1ERORPOLT 91'.f Y"l '
C�ON J which requires a permit m construct,aha,kronor,demolish,or repair any structure
priono is its...re,also requires the applicant for such Permit to file a signNsmmmem POWER DEVICES
0� chat he is licemed Purmann.the provisions ofthe Contractor's License Law(Chapter nw
p 1111
9(commencing with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOLBLECTIU !4 _ _ VAIAA'I'ION
My or that he is exempt and the basis for the alleged exemption.Any violation of OU'1'1 Ef$-SWITCI -ERMIRES
Z Section 7031.5 by any applicant for a Permit subjects the applicant to a till l Penalty of
C not more than five hundred dollars($500). NEW RESIDENTIALELECIR _SQ.fT.
❑ basoconn.(thcpropeny,ormyemployeeawithwage naz irsolecomp mabon, STORIES TYPE CONSTRUCTION
i3� will do the work,andtheswetureis not intended oroffered farsale(Sec.7144,Business
and Professions Code 'no Contrscto's License Low duets not apply to an owner of
property who builds m improves thereon,and who does such work himself or through his
own employees,provided that suchimpmvements are notintendedoroffered forsale.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within oneyearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
and..).
❑ 1,asownerofthe progeny,amexclusivelycontmaing with licevedeonwetorsn QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
answer the projut(Sec.7044,Business and Pmfessiona Code:)The Cantmcnr's
License Lawdoesna up plymanowncrofpropedy whobuildsonimpmves therean,and PERMIT ISSUANCE
who contracts for such projects with a contmewyM licensed pursuantto the Conuacnr'a
License Law. ALTER-DRAIN&VENT.WATER(FA) FEE SUMMARY
❑ I nm exemPl under Sec. B&P C fur this rcuson BACK FLOW PROTECT.DEVICE 3': ILLS
SANITARY YN
Owner —Date
RCCEIPTp
DRAINS-FLUOR.ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
❑ Ihereby affirm thmlhevenunificate of conscnno ulf-imurc,maanifcate of RECI?IPT#
Workers'Comlensation lnmmost.racenifedcopy therwf(Sce.3800,Lab C.)which FIXTURES TRAP z
IV PARK FF:P. YN
coven all etnploYee'e under this permit GAS-BA.SVSI'EM-1 INCA OUTLETS RDIVISIO#
Policy# BUILDING DIVISION RFS
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with the city inspection division. GRBASEgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXfMPT10N FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not ed completed ifthe Permit is for one hundred dollen($I0B) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
Ic
I certify that in the perfotmanceof the work for which thispermit is lamed,JOIN WATER fIFATF.R WryEMI'/CLECTR
not employ my Person in any manner so as to to o'e•abject to the Workers' PAID
Com enseti.n Lo 1 C fnmia. D 1 �''m WATER SYSTEMRREA9'ING
z P y — Date Rn'cipi#
Applicant L� Fr r 0#4 Lrl.�1�
z NOIICETO APPLICANT:ILafte makingt is Cmific tteo xemption,you shudd NEW RESIDENTIAL P[Jvl SQ.FT. TOTAL:
become subject to the Worker's Compensation provisions of the labor Cade,you must
a 7 forthwith comply with such Provisions or this permit shell be droned revoked, BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Iherebyaffi..Bud there iso omswcdon tendiagagency forthe performance of TOTAL: g7_Ll ELF,CTRIC FEB
U O the work for which this Permit is issued(Sec.3097.Civ.CJ
Lender's Name
u" Lenders Address QTY. MECHANICAL.PERMIT FEE PLUMBING HE _aD
W 1 certify Nat I have reel this application and state that the above information is
�" pk correct.l agree to comply with all city and county ordinances and state Paws relating to PERMITISSUANCE MECHANICAL FEE
ybuilding concoction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
V z above-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep harmless the City of Cupenino against
linbilities,judgmens,urss andexpenses which any ineny way accrueagaimt said City AIR HANDLING UNIT(TO I0,000CFM)
Inweseueaceof egrataing of Nis / AIR HANDLING UNIT(OVER I0,000CFM)
V�
Signature oflaipplicaduCommuctor Irate EXHAUST HOOD(W/DUCT) 3 L
PAID �'� v
HAZARDOUS MATERIALS DISCLOSURE I IEATINGUNIT(TO 100.000BTU) t�sm Raeiptp
Will the applicant or future building occupant store or handle hmurdous material
as defined by the Cupenin.Municipal Cade,Chapter 9.12,and But Health and Safety HEATING UNIT(OVER 100,000 BTI) TOTAL: �Q
Cale,Section 25532(a)7
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will the applicant or future buildingoccupant the
use equipment oralitices whichemit
8011.HR-COMP(3HPOR IM.OW BTU) ISSUANCE DATE
• haatrict? air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OVER 100,000 BTU) P A D
District? ( N
❑Yes ❑No NEW RMSIDF.NTLXL MECII. SQ.FT.
I have read the havardous materials rcq.iremems under Chapter 6.95 of the MAY 101993
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a tenet,that It is my responsibility to notify the /.
ccupant of the regaimmems which mutat be met prior to issuance of a Conifitale of
Occupancy. n'I f VC VU1'Cn I IIYI/
^.
Owneroramhmiudagent Date TOTAL: ISSUED BY: v^
OF