25798 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBING
B IL)INi-LLPffRICAL ' PERMITNO.
PL .MECHANICAL
BUILDING DIVISIONAPPLICATION/PERMIT IIUILUINC1'INGRCTIUE;VTIFICnIION
25798 C7^ O
BUILDING J)DRFS$. 1 / SANITARY NO. API'LICA'fIONSSUU�BMlMAI,DN11:1
``1111 q74}` II tvk11(c`•aA,l\ awe/. UNIT# LOT#
OW NQ 1 ./PIIONE: C OR'S NAME: LIC—NO:
!VJ 1 N/C COMROLp
6kRCI lCILT JVR LIC N ADDRE, . c(
%fq �W �rr �A• S El
CO ACI': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEC
BLDG F: PWM MECII
a PERMITISSUANCIi ��
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1 DESCRIPTION
W,mxz00 IM1erebyaf Division
inns and islnmof Ch ode,and
mmecense is th
in �s _ D /^— _ __
<W1 Senior 9(100)of Division J of Nc Business end PmPou;ov Gads,and my license is in PANELS R1!iV7 /V*tII-
f'Ialff.. LiLotcense
nse Ciar effect.
�U(,J UP TO 200 AMPS
F W Lictnse Class Lic,p
co« Omc Contrwmr 201-IOW AMPS
F-O G_ ARCI IITECI'S DECLARATION SQ.fT�R A EA
O y 1 understand my plans shall be used as public records. OVER 100CAMPS 3
SIGNS ELECTRICAL
Q Y j Licensed Professional
est< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOEU 1 thereby vhfimo that I am exempt from the Co drachms License Law far the
m3ay following reason.(Section 703 LS,Business and Professions Codc:Any city.,county TEMP.METER OR POLE INST.
C.u]to which requires a permit to construct,alter,improve,demolish,or repair any structure
wnY prior to its issuance,also rNuirts the applicant!orsuch Permit to rile a signed statement POWER D17VICF-S
6j K p that he is licensed pursuant o the provisions of the Contractors License law(Chapter
mLp�' 9(commencing w ith Section 7000)of Division 3 of the Busi ness and Pmfesaions code) SWIMMING POOL ELECTRIC VALUATION Y�
IyKj�y or that he is exempt therefrom and the basis for the alleged exemption.Any,b1.0nn of CY
Y Section 7031.56 applicant a permit subjects the applicant to ecivd II f UTLEI'S SWITCHES-MIXTURES
�z Q y hundred
teal pens y a s�
mol mom than Eve hundred dollars(SSW).
ESp NEW RESIDENTIAL ELF.CfR SQ.IT. STORIES TWE CONS'1'RUCI'ION
❑ Lasawnls,ande e....ey,ormyemPloyce.w;Nw df,,r Ne(Sec.7ompereffion,
a will do Ntwurk,ands:The,Connector's
Lienee Law
apply or smonerof
ess
and looperty wh ons Code:The improves
tendon,Liana law does not apply lf wh owns of
ownerywyces.pdsorlm donsuchimprovndwho we not imech dedoork r offered forwalhhis
employres.pmvided Nm suchimprovemenls are not intendedoraffered!.,eche,lL OCC GROUP RES.UNITS
however,the buildingor impmvemem is Sold withinone yearofcampletion,the owner. T
builder will have the burden of proving that he did not build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE ____F_1 DOD ANN
❑ I,us rofthe propcny rem exdusivdy contracting wiN licensed connanors to
tonswct Nenpto 101y,Business and Professions Coda)The Contractor's
License law d«snot apply conn ownerofpmpeny wb.bu;IJsorimpmves Nerwn,and PERMIT ISSUANCE
who corsets lin such projects with a eomm,hroa)licensed pursto m m the sroacmre
License Law. ALIT -DRAIN&VENT-WA'113R(GA) FEC SUMMARY
❑ 1 nm exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDL fF.F_s
SANITARY YN
i.� Owner DateDRAINS-PLOOR,ROOF',AREA,COND. RECIi1P #
r WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IMrtby effimtlhatl M1aveacenificete of<onummulf-insure.ora certificate of RECF.IPI'#
MIXTURES-PER TRAP
Workers'Compensmion Insurance or acetified copy thermf(Sev.3900,Lab C.)which PARK FliE Y N
coverall employees under Wiz pernot. GAS-FA.SYSTEM-1 INC.4 OUTBUILDING DIVISION RDIVISIONN
FEES
Policy#
Company GAS F.A.SYST M-Qff F P HF,CK FEE
n Ted copy is hereby famished.
Ce ified copy is filed with the city inspection division. GRPASF/INDUSTRL A 1NIERCF.PfOR G A NG FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE ` -
(Ths sretionnml not be compinedif the permit is for one hundral collars(SI W) SEWER-SANIT RY-STORM EA.NIOFT,
I3NERGY PGr ✓
less.)
(certify that in the Performance of the work for which this Permit is issued,(shall WATER HEATEW/VF ..
not employ any person in any manner so as m became subject to the Workers' PAID
Cuor",otinn Luwsol Califnmha. Dam WATER SYSTEM/IREATING Data Receipt It
z Applicant
O0 NOTICE TO APPLICANT:If,after making this Cenifiese of Exemption.you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
become subject to the Worker's Compensation provisions of the Labor Glide,you must
a ? forthwith comply with such previsions or this permit shall he deemed revoked. BUILDING FEE
F; CONSTRUCTION LENDING AGENCY SEISMIC FEE
L4 0
z I thereby affirm thatthere is.construction lending agency fared,pedormanceof
U O ELECTRIC FEE
the work fwhich Nismw
pcsil is ised(Sec.30G,Civ.C.)
or
1<ndcrs Name TY, MECHANICAL PERMIT FEF. PLUMBING HE �'
F ('now Addosn Q
V 1 certify that 1 have read this application and state that the above information is MECHANICAL FEE
>" W correct.I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
0" building construction,and hereby seal .fp
restntativty of Wiscity to enter upon the CONSTRUCTION TAX
(� Z his, mioncd y for ins ALTER OR ADD TO MECII.
I Wc)agr to ser indcm f aharmless c C y of Cupertino against
liab;lities,jue ren¢ sts and may in yw .L, f Cupeirrsbaid City AIR HANDLING UNIT(TO IQIXIU CI>M)
in cons 0 <gow in thn
AIR HANDLING UNIT(OVER IO,IXN)CPM)
1173 -
Sigi mrcof Applic.nt/Conte vo Date EXHAUST HOOD(W/DUCT) PAID
IIAPARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Rcecipt9
Will the.,hroal or future building occupant stare to handle hazardous netenal HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety TI q
Code,Section 25532(x)? VENTILATION 17AN(SINGLE RBSIU)
❑Yes ❑No
ISSUANCE DATE
Will thea licamorfum.e buildin lu.vec lordeviceswhlehemil BOILER-COMP(3HP OR 100,000 BTU)
PP gcecupan gen Air
vvdous air cameminanls u refined by the Bay Artn Air Quality Management BOILER-COMP(OVER IW,OW BTU)
R p
❑Yes C3 No NEW RESIDLM'IAL MECH. SQ.FT. W
1 have read Ne hazardous materials rcyuiremenls under Chapter 6o5 of Ne �/f(S, "yyC (I/�Q/
ifCaliforniaebuung dM1&Octcur Code,have
Sections s 25505,t it
and responsibility
I understand that {{�ye1Y1 }� `f.�Y
if the building eros ot currency haveatenant,that it is my responsibility to notify the e Q/Y'C
nccupent of the rtquiremenb which must h and poor m issuance M e Cenificam of to/��4
Occupancy. F,
Owner m authonocd agent Date ISSUED BY: 'h�Mrn
OFFICE