25170 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY ONCUPERT[NO BIILDINU-F.L.F..1'RI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBMECHANICAL 25170 5 7 0
BUILDING DIVISION BUILDING 1'R(IdEC'1'IUN;N'1'IF'ICA'1'ION L J 1
OUILDING ADDRESS: SANI'T'ARY NO. APP1,1CAI[ON SUBMITTAL DATE
scot • UND# LOT
OW E P: PHONE: CONTRACTOR'S NAME: LICNO: LLL
NIC CONTROL.
2CHITECT/BNGINEER: LIC NO: ADDRESS: ❑
CONTACT': PHONE:
QTY. ELECI'ItIC PERMIT FEE BUILDING PERMIT INhO
UD ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �'j//r/���4 JO�B�D�ESCRIPTI
py(G Ihvchy nftirm don lom llwnacJ undvprovininnsnf Chapta9(wmmcnoine with / I a�
00 Section 90D0)ol'Division 3 of the Business and Professions C.de,and my license is in PANELS
dE [ml Terse.nae 03 a�
Fyyl License Cl s Lic.p p.,�Q,� UP T0200AMPS
m6z Date�Tl Cl StDrC RAI a"` - Z01-1000 AMT'S "g,�., SQ _ AR SISQ.FT.
ZZ-Q OVER I(Xq AMPS ,I U `•\
p Z,o, 1 undmtand my plans shall he used as public records, t
f; SIGNS ELECTRICAL p1I Ips ''I¶I' �(��•
gq' Licenud i'rofcssionnl OWNFR-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC. •V, `✓ u '�
yxOiF a hereby affirm that I am exempt in from the Commons License Law for the -/-� -�
co following«aum.(ration 7031.5,Business and Professions Code:Mycity or county TEMP.METER OR POLE(NST.
k �� which requires a permit to construct,alter,improve,demolish,or repair any structure
�yT� prior to its wit unce,alsoaquires the applicant for such permit to file a signed statement POWER DEVICES
y�ja pp that he is licensed pursuento the provisions of the Contractor's License Law(Chapter
0. 0�• 9(commencing with Section 7000)of Division 3 ofthe business and Professions Code) SWIMMING POOL.ELECTRIC VALUA'T'ION
_sy Ortho,he is esanpttherefmod andthc basis for theallegcd exemption.Any violetimn of OtJI'LEI'S /4tea• O
I-ZQ Section 7031.5 by any applicam for a permit subjects the applicant m a civil penalty of SWITCHES-FIXTURES
not marc than five hundred dollars($500).
�o ❑ 1,asowneropM1epmpeny,ormyemployeeswith wagcsas theirsalecompernabon, NEW RESIDENTIALELECIR —SQ,ET. STORIES TYPE CONS'IRUCI'ION
i3= willdn the work,and the structure is not mandalmouffcrcd for sale(Set.9044,Business
and Professions Cole:The Contractor's License Lew does not apply to an owner of
property who bu ddsm impmvor thereon,and who does such workhimself or through his
employees,prnviJW that such improvemenlsare nm intended arafferedforsale.If, OCC.GROUP HER,UNITS
however,the hu idingorimprovement is sold withinone yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,snowner ofthe property,sat exclusivelycontmcting with licensed contractors to QTY. .PLUMBING PERMI"P FEE FLOOD ZONE APN
constrict the project(Sec.](144,Business and Pmfeadoes Code)The Cotnraclnr'e
License Law Joevnot apply roan owncrofproperty who builds m unproves thercon,and PERMIT ISSUANCE
who contracts f.rsoch projects with acomractor(s)licensed pursuant to the Contuarors
License Law. pLIER-DRAIN&VENT-WATER(HA)) FEE SUMMARY
❑ I tan exempt ander Sa. ,B&P C for this reason BACK FLOW PRO(ECT.DEVICE '1 If: FS
SANITARY Y N
Owner Data #RAINS-FLOORROOFAREACOND. RECEIPT#
. . , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN_
I hereby affirmtbal l have.certificate ofcomsemm self-insure,.,ucemronte of FIXTURES-PER TRAP RIiCF.I PIF#
mkers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
colas ell employee's undenhis pconit. .g/I �T GAS-FA.SYSTEM-I INC.4OUTLEfS RECF,IPI'N
Policy OL (/ BUILDING DIVISION FEES
Company O GAS-FA.SYSTEM OVER 4(EA) PIANCHECK FEE
❑ Ceniflcd copy is hereby formation,
Cenificd copy is filed withtae city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be camplacd Boar proard is forane hundred delta.P$100) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this permit is issued,Ishnll WATER HEATER W/VENT/F.I.ECfR
not employ any person in any manner so as m become subject t.the Workers' PAID
Compensmi.nl.awsof Califomin. Dom WATER SYSTEMrrREN'ING Date Receipt
0 Z Applicant
Z NOTICE TO APPLICANT:It,after making this Cenificmc of Exemption,you should NEW RESIDENTIAL('LMB. SQ.FT. TOTAL:
F (q become subject to the Worker s C.mpeasaOon Provisions of the labor Code.you must -
� ; fonhprevisions with comply with such pvisions or this permit shall be deemed revoked. BUILDING FEE
W
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby affirm that there is a construction lending agency for the performance of
U t'tr island(Sec.30D,Civ.CJ TOTAL: ELECTRIC FEE
O the work for which this Fermi
lender's Name U PLUMBING FEE lenders Add.. QTY, MECHANICAL PERMIT FEE
1 certify that I have read this application and stemta
that e above information is
W
�-' D.1 comm.(agree mcomply with all city and county ordinances said state laws retmingm PERMIT ISSUANCE MECHANICAL FEE
Jbuilding construction.and hereby tmthorize representatives of Nis city to cmeruponthe CONS'IRUCTIONTAX
V Z above-mentioned#miserly for impecti.n Families. ALT ER OR ADD TO MUCH.
(We)agree to save,indemnify and keep humans the City of Cupertino against
Ilabiliticiijudgmena.costsanln,warswhichmay in any way ecome against said City AIR HANDLING UNIT(TO 10,000 CFM)
onsequen a..,an granting oft rmit. 7—/S..QJ IM
AIR HANDLING UNIT(OVER 10.000 C )
Signature of Ap mOCono m Goal EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE ILEA'riNGUNI'I'(9Y)I()11,MDBTL1) Dale Rreip,a
Will the applicant or furore building occupant store or handle hazardous material IIGTING UNIT'(OVER 100,000 BTU) TOTAL:
as defines by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section
❑Yee 2(a7+ DNo VENTILATION FAN(SINGLE RESID)
Wllhhe npplicanwrfumrehuildingoaupanmvecyuipmemordevioes which emit BOILER-COME(311P OR 100,100,00i, D BTU( ISSUANCE DATE
zoomm,air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID
` M A
mstrictP /1 Y
❑Ycs ❑No NEW RESIDENTIAL MECII. SQ.FT. /p
I have head the mastodons materials requirements under Chapter 6.95 of the JUL gw p/5
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that U� �t 4 w
If the building does not cumailly have a tenant,that it is my responsibility to m dfy the
accupanl of the requirements which must be met prior to issuance of a Cenificule of
Creation, CIl t J u rc
Owner or aolhorized agent Dam TOTAL: ISSUED BY: