25947 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUIIESION DUILUJNU-ELLUI (CAL
PERMITNO.
APPLICATION/PERMIT PLUMBING
BUILDING DIVISION UUJLDING PROJECT IDENTIFICATION 25947
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
IT#Tr . LOT#
OWNERS NAEO CTOR'S NAMELI NAME
: O:
N/C CONTROL#
ARCHI I LC 17ENGINEER: LIC NO: A DRESS0 ❑
CON ACT: PHONE: BUILDING PERMIT INFO
�1r &U:5- 377-'`15/2. QTY. ELECTRIC PERMIT FEE
ELECT PLUMB MECH
PERMIT ISSUANCE E El
LICENSED CONTRACTOR'S DECLARATION IR
APPLIANCES-RESIDENTIAL
1]02 Thereby of
roamhat I 3 of the
Profesime,Cash,
mmecense with - x[10 � ' J j
tr100 Section e nd e f Division 3 of the Business and Professions Code,and my license is in PANELS
Fye V full force and effect _ O
2 License Cl ass LIC.# UP TO 200 AMPS
1,i<vi Date Con[mcmr 201-I000AMP5
ZOvrns CHITECT'S DE 201 I OOAMPS SQ.per.FLOOR AREA $/SQ.FT.
O z— 1 understand my plans shell be used as public records.
SIGNS ELECTRICAL
aaid -� 'L¢ensed Professional
.reJ 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUGIMISC.
KOyF I hereby affirm Nal 1 am exempt from the Corrosion's License Law for the
W 3O- following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
ry'Y� lonatoi[stssuance,alsoreyuires the applicam(crouch permittofile aligned statement POWER DEVICES
iG C, that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL BLE C
e 9(commencing with Section 70M)ofDivision 3 of the Business and Professions Code) VALUATION
or than he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLEfS- �a
6 Section 7031.5 by any applicant(orepemtit subjects the applicanuo acivil perWyof SWITCHES S /���t ,ter
mt mora mrn five hundred dollars(5500). NEW RESIDENTIA ECB _SQ.FT. /
n❑ oche wrk,andepmpeny,armyemployedorofned torstheirsea.7=7.Esiness STORIES TYPE CONSTRUCTION
a will domesions and the he Contractors
License
La does not a Sec.to cm Business
and Professions Code:The Contrncmr'e Littnse Law rices not apply m rn owner of / eV•f•/,/
properly whobuddscrimpmves theroomand whodoes such workhimselfordocugh his OCC.GRO
own employees,provided that such improvements are nn[intended or offered for sale.If, UP RES.UNITS
however,the building or improvementis sold witainnne yearofeampletion,theowner- ,TOTAL: r
builder will have the burden of proving that he did not build eximprove for purpose of r
sale.).
❑ Las ownerofthe property,am exclusivelycommeting with haensalcomangtorsto QTY. PLUMBING PERMIT FEE ".'UNIAPN
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's
License Law does not applytonnownerofpropeny whobuildsorimproves thereon,and PERMITISSUANCE
whocon"ctsforsuchpmjeclswifoac.nencmr(s)licensedpursuantmthe Contractor's ALTER. FEE SUMMARY
License Law. (EA)
❑ I em exempt under Sec. ,B&P C for this reason TSIDE FEE
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner Data— DRAINS-FLOOR,R �JN 4,.. S LTAX YECEIPT# ry
WORKMAN COMPENSATION DECLARATION
covers(hereby affrmtM1mlheve acertifcare of consent mself-insure.maceniftnete of .. v RECEIPT#
FIXTURES-PER TRA r
Works all
'employsation lnsumnoa orettnified wpy thareof(Sa.3800,Lab CJ which P FEE Y ry
Policy
� Pnni= GAS-EA.SYSTEM-I 4� UJ'L RECEIPT#
Y BUILDING DIVISION FEES
C°mPanY /w�rpw-M �, �— GAS-EA.SYSTEM-OVE 4
❑ Centfed copy ie heuby fumi e. LANCHEC FEE
❑ CeniFied copy is fled with me city inspection division. GREASIVINDD WASTE ER EPTOR GRADING'FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - SOILS FEE
COMPENSATION INSURANCE
(This section rad not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY- ORM P.A.200FT. ENERGY FEE
or less.)
I acidly that in the perfomtance of she work for hath th' acern is issued,I shall WATER HEATER ENT/ELECTR
nor employ any a n any manner so ee t to the Workers' PAID
z Compensation n 1' te. Gb WATER SYSTE REATING Date Receipt#
Q APPlicent
z NOTICE TO LI If,afar making Nis Certificam of Exemption,you should NEW REBID IAL PLMB. SQ,PT. ALo
f/] banmesubjauo rh is Compensation provisions of the Labor Code.you must
forthwith comply with suet provisions or this perm it shall he deemed rovoked. BUILDING FEE �e
ay
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz T hereby affifinhick t Nanhere is a construction lending agency for she performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEE
F LeadersIaiAddress QTY. MECHANICAL PERMIT FEE
L) 1 cenity that I have reed this application and state that the shove information is
correct. cogreemamply with all city ou comfy ordinances and state tawsrelatingupon
due PERMITISSUANCE MECHANICAL FEE
U y buildingconstruction,proand herebyauction p rpses, tives of this city to entaupon the CONSTRUCTION TAX
(� above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m move,indemnify keep harmless the City of CuPenlno against
lnamities,judgmc I costs indexpe es hitch may in any way acerve against said City AIR HANDLING UNIT(TO 10.000 CFM)
ansequen ft tango th' it
AIR HANDLING UNIT(OVER IO,f W CPM)
Signature f lice incontractor Dat EXHAUST HOOD(W/DUCf)
01
PAID
HAZARDOU TERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Da¢ ReceiptR
Will site applicant or future but ding occupard.nom or handle Imeardaus material HEATING UNIT 100,0008 ) T
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda,Section 25572(a)7
El Yea 0 N VENTILATION PAN(SINGLE SID)
ISANCE DATE E
Will thea pIicamorluwre buildingoccupanfusee ofpmennrdevices whichemlt BOILER-COMP(3HP OR ,"BTuy A
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OV 100,000 BTU)
Olslrict7
❑Yes ❑No NEW RIiSIDENTI MECH. SQ.Ff. Fan 94 1994
1 have read the hazardous materials requirements under Chapter 6.95 of the C�I Ur w
California ia Health&Safety Code,Sections 25505,M533 and 25534.1 understand that I
if the building does not currently have a tenant,that it is my responsibility to notify the
ertipaoccupant of the requirements which must be met prior to issuance of a Carlfiwte of _
Occupancy.
Owner or euthoriud agent Data, TOTAL: ISSUED BY:
OFFICE �