25330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES--USE BALL POINT PEN ONLY
CITY OFCUPERTINOB I. I .- .L.0 RI A PERURNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25330
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADD ESS: SANITARY NO. APPLICATII�ONNSUBMI]TALDATE
LOT# �� V
OW ;R A F.: r' Nl ^� SoCIOR'SN ME: D 1 n_LIC NO N/C CONTROL#
RCHI'TEC'OENGINEER: LI O: DR S: DOP M , .1Si
24
CONTACT: PHONE IBUILDING PERMIT INFO
�^I\��(�((` 1-N�11k QTY. ELECTRIC PERMIT FEE
�Aes 1.'VU1 bPj -r-17SI2_ PERMITISSUANCE BLDG ELECEl
T PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Ir 1lOB pL,tiOUP11 N
pyz, Ihcmby a(fuLICEN E licensed under ACTORProvisions DECLA ha DECLARATION
with 1•'sl fY/'fV 1JlV
u100 Section]OW)of Division3 of the Business and Professiom Code,and my licrnuis in PANELS
yFy�W full farce and effect(�//1QI -]�i_1 'mss
Qzel License Clea I 1 Lic.p J ,D UPT02MAMN
rliaQa Dale Contmnm C 201-I000c AMPS ...JJJ
Or`y'irz ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
Z
OO,G 1 understand my plans shall teased m public recoMs.
OVER 1000 AMPS
r4 W SIGNS ELECTRICAL
Qg - Licensed Pmfeuime
CC Q OWNER-BUILD ER DECLARATION C.moION SPECIALCIRCUIT/MISC.
ya4O myF 1 hereby affirm the I am exempt from the Cnsions Cs Code:
law for the
ftillowt+130m which ingrasoa.ermit(Section
tocommo ,ever, and improve,
Co de:Mycin orcountyucture TEMP.METER OR POLL INST.
w which requires a permit to COnswcL alar,improve,demolish.m repair my structure
>� prim to its issuana,alsorequires sheapplicam for aochpeaniuofileasignedslamment POWER DEVICES
u] pC that he is licensed purseenrao the provisions of the Contractors License Law(Chapter
L�'eLL 9(commencing with Section 7")ofOivision 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
to or that be is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 0
EZa Section 7031.5 by any applicant for a Permit subjects the applicant to a civil pernety of Soo,
U U
not mom thm five hundred dollars(55W).
es ❑ Lerovurrof thepropenyormycmployeaswithwagexastheir solemerfamation, NEW RESIDENTIAL ELECTR _SQ.PT. STORIES TYPE CONSTRUCTION
a3— will do The work,and the rwcme isnot lmmodedoroffined far sale I'm.0044.Business f
and Profexxloma Code:The Conrmemes License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himsel f or through his
ownem Io us,pmvidedthm such improvements OCC GROUP RES.UNITS
p Y provenmmsarcne inundreompleercd theoe.lf.
however,the have
the
or bedeprovemem is said within in onryear or comm Bion,m purpose,
of TOTAL:
builder will Iwve th<dWen of proving that he did not build or improve for puryou of
ale.).
E] Las owncrofthepropeny,amexduxivelycontrmting withliccnsW conunctoym QTY. PLUMBING PERMIT FEE FLOOD ZO E ANN
construct the project(Sm.7040.Business and Professions Cade:)The Contractors PERMIT ISSU.�FJCL fi
License Low does not apply to m owner of pmpeny wha bui Ids a improves thereon,and
who contracts foreseers projects with aconvactor(x)Iicenud parent mthe Contractors PETER-DRAIN& -WATER(RA)• I1-t. FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PR -DEVICE "/j OUTSIDEFEES
TARY Y N
Owner Data RECEIPfN
DRAINS-FL R,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION OOL AX YN
Woalhertbrnpeopm Nmlhave acerifim fiefs theos f(Sc,rgoracbC.),vmaf FIXTURES PRTRAP RECEIPTN
Waken Compens's nlnsumnuorecenifed copy thereof(See.3ti,lab CJ which CAg-EA.SYSTEM-I INC.40lIT1.Ef5 AR_K - Y N
Policy dl employee's under this permit. ID7 FIs(IO r6 S RDC DIVISION
Policy I BUILDING DIVISION FEES
Company 4141 TJw GAS-EA.SYSTEM-0VM4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
CcriffW copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FTSE
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASETRAP SOILS FEE
COMPENSATION INSURANCE.
('This section and nm becompleted ifthe Permit is creme hundreddo11ay(SI00) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I certify that in the performantt office work for which this permit is issued,)shall WATER HEATER W/VENT/LLECTR
not employ any person in my manner so a to become subject to the WorkersPAID
Compcnsationlawsof California. Daze WATER SYSRIK(REATING Dam Receipt It
Q z Applicant
NOTICE TO APPLICANT:If,afar making this Cerlficare of Exemption,you should NEW MIDEHTIAL PLMB. SQ,PI. TOTAL:
FFFa
(q become subject to the Workers Compensation,provisions ofthe Labor Cade,you must---"' ; forthwith comply with such provisions or Nshal
Nis permit l be domedBUILDING FEE
revoked. _w
Z FE
CONSTRUCTION LENDING AGENCY SEISMIC E
1 herehy affrm the there is a concoction lending agency for the parnmrmmce of
the work for which this permit is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC FFE
LUl. O Lenders Name PLUMBING FEE
r' Lenders Address QTY. MECHANICAL PERMIT FEE
W1 certify than I have mad this application and come the the above infomeEm is MECHANICAL FEE
P. coven.I agree to comply with all city and county ordinances and scam laws relating to PERMITISSUANCE
F" building construction,and hereby authonu represrnmives ofthiscity menter upon the CONSTRUCTION TAX
V above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree m cave,indemnify and keep hermless the City of Cuperiro agaimt
liabilities,judgmenfs,costs and expenses which may in my way a¢ againsft said City AIR HANDLING"IT(TO 10,0(111 CFM)
imcotsscqu`ncp of the nngp o p: � I� AM HANDLING UNIT(OVER 10,1100 CFM)
fiiggninaAtmrc'nffAA/pplicanUCo r Icor la-v' etc EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the the Cuanrtinl or oMnicure ipal Code,ng pere haper9.o.hurdle hawdous h and Safety
HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cal
defined by the Cupertino Municipal Code,Chapter 9.12.and the Health send Safety
Code,Section 2553200?
0Yev )3,H. VENTILATION PAN(SINGLE RESID)
ISSUANCE D
Will the applicantorfmwe buildingoccupanf useequipment rdevicawbichemil BOILER-COMP PHP OR 100,IX0 BTU)
hazandous ab conuminants uftn
dead by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
strict]
❑Ya No NEW RESIDENTIAL MECH. SQ.FT. PAID
1 have read the hmardom mammals requirements under Chapter 6.95 of the
Califamie Health&Safety Core,Sections 25505.2553]and 23534. 1 undeywnd Net
if the building does not currently have a mnanL dial it is my mapon Atility to notify the - Arl
18 Q
occupant of the r quiretpepu wryry,c�Is ^ t h p1 poor to issec �f a Cr ca¢of VAN1(U
r�tGS 1r^(Si/
authorized.bin s Dee TOTAL: ISSUED BY:
OFFICE