25319 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO m>RDfNG-ErEC'T I", - PERMITND. 25319
APPLICATION/PERMIT PLUMBING-MIICDANICAL
BUILDING DIVISION BUILDING PROJF.C'1'11)FN'1'IFIC,A'I'ION
BER
�I '/YD ADDRESS{/ � a�-- �•ry /I�.,,s,.( I SANITARY NO. 5.ATIONSSUBMITTTAL DATE
I!5 / /ae'ti�-/��`\ (i- UNIT NN LOT#
OyRyQTERS M(Cf D � �// IjONE: �Ll CONTRACTOR'S NAMF1 �/ LIC NO: NIC CONTROII.N
ARCCHIITE/CTII/LENGINEER: ;97C LIC NO: f ADDRESS: .(� ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG kFC1 PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S ATION APPLIANCES-RESIDENTIAL 70 � �
q'2 1 hereby affirm(hat l aEDlicensedCONT uACTOR'S D ns of Chapmr9(commencing with
00 Section700dof Division 3ofthe Businessmid Professions Cole,and my license is In PANELS i ��
C�jEf1 full force and efl'cet UP TO 200 AMPS 0 f �
F7W License Class Contract
lam4
A,
y Rule Cnmraclor 201-1000 AMPS"
ZON2 ARCI IITEC'PS DECLARATION OVER I"AMPg SQ.FI.FLOOR AREA $/Sp.PI.
OZ4q l understand my plans shall be used as public records.
r 4 SIGNS ELECTRICAL
Licensed Professional
a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOgF I hereby affmn that 1 am exempt from the Convector's License Law for the
W 3 W m following rcmon.(Section 7031.5,Business std Professions Cade:Any city or county TEMP.METER OR POLE MST. x D f
which requires a permino enw
nsm,¢Iter,improve, ir a
demolish,car repany swcture -
K�Q� prior m its issuance.also requites theapplicam forsuch Permit file aligned statement POWER DEVICES
W,pO that he is licensed pursuant ¢
o the provisions arrive Comrrors License Law(Chepm �
r 4 as N
gXe0' 9(commencing with Section 9000)of Division 3 ofthe Business and Pmfwions Code) SWIMMING POOL ELECTRIC J VA T )
W—Q or M1ei31.5 by exempt therefrom the bamansfor bjealleged exempPIrcon Ian. Civil
penally
of OUTLETS ,S
h Z.<0 Section ]hest by any applicant fora permit subjects the applicunno a civil pendty of s��
WN. not mom than five hundred dollars($500). NEW RESIDENTIAL ELELTR _SQ. NSTRLICE IO
❑ 1,amwncro0hepropeny,ormyemplayees wirhwegesmrheirsole compensation.
q3_ will do the work,and doatrecmbris not intendedoroffered forsnle(See.74,Business ax
and Profess m Code:The Contrumo's License Law does not apply to an owner of
property whobuildsor improves domonead who does such work himselforthroughhis -
nwncmployee.,provitled thud such improvem<ms arcnot intended proffered(ansate.If, OCC.GROUP RPS.UNI'T'S
however,the building or improvement is sold withinatie yearofcompletion,the owner. TOTAL:
bonder will bnve the burden of proving that be did not build or improve for purpose of
s la). n
❑ 1.0s nwnendthe pmpwny.umexcluvivdy cpnir...ingwilh licensed contractors to QTY. PLUMBING PERMIT FEE? FLOODZONE APN
construct the project(Sec,70,14.Business and Professions CodcJ The Contractor's �^
License Liovdnes no,apply manownerofpmpeny whubuild.or impmveadomon,und L PERMIT ISSUANCE",
whocordown forsuch projects with econtractar(s)licensed pursu.at to the Commucmis pI TEA-DRAIN&VENT-WATER(EA)License Law. FEE SUMMARY
❑ lam exempt under Sec. ,B&PC for this brawn BACK PLOW PROTECT.DEVICE SANITARY Y OUTSIDE S
N
Own<r Data REC I1 #
RO
, OFAREACONED
, , .
WORKMAN COMPENSATION DECLARATION DRAINS.FLOORSCHOOI.'fAX YN
❑Workers'
affirmon Insurance ora cinfie coeard ffthe selFimure,or crani.)am which Fl%TURPS-PF.R TRAP REC—Li
Pfp
Workers'Campcnaetionlmurance oraccnified copy Nertof(Sea 3800,Lab C.)which � � PARK FEE YN_
covers all employees under this permit GAS-FA.SYSTEM-I INC. 0UTLETS RECEIPT'p
Policy# BUILDING GIVES FMRS
Company GAS-EA.SYSTEM-OVER 4(RA) PLANCHECK FEE
❑ Conifted copy is hereby famished.
❑ Cenipied copy is filed with Ne city inspation division GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CEI+TIFICATIi OF EXEMPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forotiehundrcd dollars($100) SEWER-SANITARY-STORM EA.200FT. FNF.RGY HE
or less.)
I certify that in the Performance ofthe work for which this permit is issued,I shape WATER THEATER W/VENT/ELECIR
not employ any penton in any.untie,so as to become subject to the Worker,' , PAID
Conmpmmulin t Luwsof California. Data WATER SYSTEMREATING Data Receipt
Z+ Applicant'
NMicE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.111'. TOTAL:
a^ rte-. become subject to the Worker's Compensation p,ovisiom of Ne Labor Code,you must
tai forthwith comply with such provisions of this permit shall be deemed revoked. BUILDING IEE
GIca CONSTRUCTION LENDING AGENCY - SEISMIC FEE'
U 2 Ihemhyaffirmthatrhere is is tr
consuctiole
n nsingageney nor the performance of
O the work far which this permit is hared!(Sec.309),Civ.C.) 'd Ai ELECTRIC ME
Lender.Name O a PLUMBING FEE F Landes Add.. QTY. MECHANICAL PERMIT FEE ,sss '
U I certify that p have rend this application and amt¢tMt the above information isM
cored legreemcomply with alp city and county ordinances and sant laws minting m PERMIT ISSUANCE MECHANICAL ME
Lo) building construction,and hereby smhoriu repreunmtivesof Nis city to enter upon the
U Z above-mentioned property for inspection purposes. AUIER OR ADD TO MECP. CONSTRUCI'IONTA)(
(We)agree to es.¢,indemnify and keep hrood.the City of Cupertino against
liabllities,judgmems,costcandexpensea which may inanyway amus,against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signnum of Applicant/Contmnor Dam EXHAUST HOOD(W/DUCD PAID
I IAZARDOIJS MATERIALS DISCLOSURE IIEA'1'ING UNIT(TO E00,000 BTU)��/`� �� Date Receiptq
Will rhe applleont or future building occupant store or handle hazardous material
as defined by do,Culmnino Municipal Code,Chapter 9.12,and the l lealtM1 and Safety I HATING UNIT(OVER 100,000 BTU) 'f
Code,S.1ion 25572(0)'7
❑Yes IJ No VENTILATION PAN(91NOLE RESID)
BOILER-COMP(3HPOR 100,0000TLU
ISSUANCE DATE
Wus airacontuammfuturc building by the Bay Area Air
unlit Management JUL
.•harnNous air cnmantinams m defined by the Bay Area Air Quality Management BOILER 100,000 BTU) 1�1AQ
DinrictP ��77�93
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.IT.
SII Y Ur "Urrmil 11�
I have read the hazardous materials requirements under Chapter em of the LI(� / /^I Q N�� V
California Heahhs SafetoLSEl Cade,ae a hard,
it
and 25!04. 1ity m imnd that /�
iftM1e building Joeaneem have asrnmbtBm it is myrespomiof.Crtnmify the
occupant oft b must hem car m issuance of a Certificate of
Owner or unthomcd agcM Data 0 ISSUED BY:�