25383 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO7"-FLEUJRI•AT" PERMITND' p r�
APPLICATION/PERMIT PLUMBING-MECHANICAL O J
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDINNGAA�DJ,DDRRESSS: {� SANITARY NO. APPLICATION SUBMITTAL DATE:
06 06 O • UNITN LOTH
OWNER NAME: PH�N ^ �,S C YI' ORSNAMEAIM LCNO� t.OL
N y ]L NC C NROLM
ARCHITF: T/ILNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PL MGCH
PERMIT ISSUANCE ❑ 0 ❑
LICENSED CONTRACT'OR'S DECLAR,%TIOP APPLIANCES-RESIDENTIAL JOB DESCRITIPION
OZZ I hereby affirm that l an licensed under provisions of Chapter 9(commencing with
{FJO2 Sonora 7000)of Division 3 of the Businessman]Professions odc,and my[taus is in PANELS 4 1�� sof ,
ca:F FE� full force,mod J U
VU q �I UPT02MAMPS
uo<eu Date ;L�Lic.M /— LS s
y« Date
Contractor 201-1000 AMPS
F'z ARCHITECTS DECLARATION OVER I"AMPS SQ.F1'.FLOOR AREA b/SQ.FT.
;1C Oz/.^—n l understand my plans shall be used as public records.
D
rtmF; SIGNS ELECTRICAL ® I
<Y 2,4 Licensed Professional
=',,:< OWNER-BUILDER DECLARATION SPECIAL CIRCUEDMISC.
�Edc sou 1 hereby affirm that 1 am exempt tram the Contmetors License Law for the f
ts1'3ay following reason.(Section 7031.5,Business and Professions Cade:Any city or countyTEMP.METER OR POLE INT.
F 4 0< which requimx a permit m conslmct,ager,improve.demolish,or repair any t rtmum I�I
T;F prior to its issuance,also renuires the applicant for such permitto file a signed staoment POWER DEVICES
'=<o that he is licensed pursuant to the provisions of the Contractor's license Low(Chapter SWIMMING POOL ELECTRIC
6604 9(commencing with Swtiom IIlW)of Division J allow,Business and Professions Code) w
TO�
m=m or that he is exempt dicrtfnni the basis for the alleged exemption.Any viohdon of OUTLETS-SWITCHES-Fl%TIIRES J
Z 4 Section]OJ[.5 by any applicant for a permit subjects the applicant to a civil penalty of W
W!=. not me Into rofih pm dollars($50b. NEWRESIDENTIALELECfR _SQ.ET. STORIES 'TYPE CONSTRUCT ION
K F-p ❑ Las,wrk,and epropcny,orm et imenyeuwithwegesastne(Sm.compcuiness
y3e—r will dr thewons.nee The Contractors
License, off<rdd
snot apply to an owner
and Professions Code:The Crmrvctor's hicenx Law Jma not apply to an owner of
prepedy who builds or improves thereon,and who docs such work himself or through his
own employees.providedthatsuch impmvememsme notimendedorifferd burials.If. OCC.GROUP RIiS UNI US
however.the building or improvement is sold within one year of completion,the owrwr. TOTAL:
builder,will brave the harden of proving that he did art build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
C] Lm ownerrftnepropeny.amexdusivelyconwning with licensed contmcmrsdo
onstmct the project(Sec.]014,Business and Professions Cale:)The Cmndnmm'a 1
License Law does not apply loan ownerofprmpeny whsbuilds or intpmorsrbemumand PERMIT ISSUANCE `
whmcmanwvforsuch projects with.comracur(s)licensed porsuanl m the Crntracmrs
License law. pL'i'ER-DRAIN&VINT-WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B A PC for this reason OUTES
HACK FLOW PROTECT.DEVICE SIDE L
SANITARY YN
Owner Dam DRAINS-FLOORROOFAREAGOND. RECEIFI'N
, , ,
WORKMAN COMPENSAI ION DECLARATION SCHOOLTAX Y N
❑ Ihcrtby affirm then hav<a<enificate of conunno ul&insurt,ora cenificam of Fl%TURES-PER TRAP RECEIPfp
Workers CumKnoinion Insurance or a certified copy thereof(Su:.3800,Lab C.)which PARK FEF. Y N
covers all em(iloyc�y uadrj]hy lxrmiL GAS-EA.SYSTEM.I INC.4 OUTLETS RDIViSION
PolicyN Dlilo�-] BUILDING DIVISION FCF'_S
Company T �,II GAS-EA.SYSTEM-OVER 4(CA) PLANCHECK FEE
dfieri copy is hereby funtished.
Xfied copy is Ned with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING TUE
CERTIFICATE OF EXEMPGON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed[fthe permit is furore hundred dollars P000) SEWER-SANITARY-STORM V.A.200FT. ENERGY FEE
a,less.)
I ceiify,had mine performance of the work for which diva permit is issued,l anal[ WATER HEATER W/VENUELEC
not employ any person in any manner so u to become subject m the WorkersPAID
Compensmionlawsof Califoroia. Date WATER SYSTEM/ITTIVUNG Date Receipt#
zz Applicant
NOTICE*10 APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FIL '1'OI'AL:
become subjeeno the Worker's Compensation provisions ofthe labor Code.you must
>
forthwith comply with such provisions or this Permit shall be domed revoked. BUILDING FEE
W SEISMIC FEE
(� CONSTRUCTION LENDING AGENCY
tI hereby affirm Nat there is a construction lending agency for the performance of
U O TOTAL: ELECTRIC FEE
the work for which this Permit is rased(Sec.3097,Co.CJ
Lenders Name PLUMBING ME
lenders Address QTY. MECHANICAL PERMIT FEE
C U 1 certify that I have read this application and state that Ne above information is MECHANICAL FEE
�•' 2.1 correct.Iagrte to comply with all city sold counry ordinances and starclaws rtletingm PERMIT ISSUANCE
F-' Cn building construction,and hereby.mhmire representatives ofthiscity to cater upon the CONSTRUCTION TAX
t.1 z ntwvo-meniioned property for impectlom puryaees. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and k5P less the City of Cupertino against
Bond fics.' Jgmsnte,crrta.aJ exper11 seaw ch n.my w�yaz ag st said City AIR HANDLING UNIT(TO 10,0X0 CFM)
inco q nc fib gr dingo AIR HANDLING UNIT(OVER I(I,WU CPM)
Si mm of Applica uc. scut Dam EXHAUST HOODfW/DUCD
PAID
IIA ARDOUS MAT HR1ALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Rccciptp
Will the applicant or future building rccupant sore or handle haaarder,material TOTAL: a,
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health malSafety HEATING UNIT(OVER 100.000 BTU)
Code,Seoimm 25532(4)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will theapplicantorfutumbui[dingmcupaat tomenuipmem rrdevices which emit BOILER-COMPOHPOR 100,1100 BTLI
azardous air contaminant,us Jcfinsd by he Bay Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU) fIryry p
Dutra] P A D
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.FT. -
1 have reed the humudam,Safety
Code.
materials 5105.25533 under Chapter innervated
ed the JULn p .�__
California builingmis&gaiety Cale.ave ate25505,25531 it 25534. [understand Net VF1 Ey��II�YD��(T/jrJ�JJ��/\
ifthe building doss not currently have a most
no aNat it is my responsibility to ramify the
Oven,
nt tar Ne rtnnhemem,which moa rte mad pia tr iaaaaace of a cmirpme of CI l Y I +
fxeapaner. h gV
Owner or awhomcd agent Date TOTAL: ISSUED BY: