25042 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-BLUM MO. PERMITNO.
APPLICATION/PERMIT. PLUMBING-MECHANICAL. C O A
BUILDING DIVISION BUILDING PROJECTIUEN'['[FIC.A'PIGS J 41
BUILDING ADDRESS:
� ► �I( �n/^� �//�Q�L SANITARY NO. AITLICA'1]ON SUBMITTAL DATE
O L �/� �bt W ,�(NITX LOTX i YV3
OWNF,�SN .: STof, PHONE: CONTRA 'S NAME: LIC NO: 7
(" NfC COM'ROLX
• aw
ARCIII'ILCI'/ENGINEER: LIC NO: ADDRES : ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MPCU
PERMH'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R ID AL / Y JOB DESCRIPTION
azz I hembyaQirn that l am licensed under pmvisionsof Cbapter9(cmnmencingwith !�
[v100 Seaion]1XI(1)of Division 7of the Businew and Professienn Cade,and my license is in PANELS
Ffy�� full forcand effect. .
44 License Class Lic.B PTO2 ) PS
y6a Dae Contract. 01- MPS
7y SQ.FT.MOOR AREA S/SQ.IT.
~,z ARCHITECTS DECLARATION AMPS
Or
OZ-0 I understand my plans shall be used as Public records.
Pr j NS F.LECTR AL
Qg -1 Licensed Pmfcnonal
FL: OWNER-BUILDER DECLARATION SPECIALCI ISC.
XOiO I hereby affirm bar 1 am exempt from the Convector's License law for 0c
m3 ay following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.M RPOLE INST.
[-E:O which rcquims a permit m mnswct,alcor,improve,demolisM1,or rtpair any swaurt
prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
Q O that he is licensed pummmt min,provision,mI the Comrucmrs License Law(Chipar
d 9 th Scction](XIO)mf Division 3ofthe Bodressand Profetimnh Code) SWIMMING I'OOl44\0 VALUA'I'Oy�'
Xo�' (commencing tui — G
Wy_, or that he is exempt herefrom and the basis far the alleged exemption.Any violation of
FZQ Seaion]OI LS by anY eppliamforapermit subjects the epplicanitoacivil penalty of OGTLETS-SWIT - U - L car
0 et marc than Got hundred dollas($501 NEW R[51 DENTI L 'Q.le STOR19 'TYPE CONS THUCI']ON
� m ❑do wncroftd mc,I...nom imyempended.,o wagesus@e(Ser.comp Business
will dofrotor,Cde:the Contractor,
atomendese Law uesol not,(Sec.1.an One,of
and Profusions Cade:9'he improves
ttacmrs License Law does such or apply lf an owner of
ownenywhobaBdsorimprocesthemnaarawhmdmeswinteMedorofemdornalfor n e.hf, OCC.GROUP RFS.UNITS
emr.theb,pingor improvement
iovem within ne eaofcompffemd throws-
huilder theavete brimprovementishathwithinoneyear or improve
thrower- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT ME FLOODZONE APN
❑ I,asownerolthepropcny,amexclunivclycontfactingwiJJicensrA canvunnn to
continue,the project(Sec.7044.Business and Professions Code:)The Contractor's
License Law Jmcs applyiomownerofprmpenywhobuildsmimpmvestheremn,and FERMI r ISSUANCE
whommocts fmsuch projects with acmurvnm(s)licensed normant mmeCtsunmEr's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I em exempt under Scc. 0&P C fur thio reason BACK FLOW PROTECT,DEVICE OUTSIDI:I'I:I:S
SANITARY Y—N
—
Owner Data DRAINS-• FLUOR,ROOF'.AREA,COND. RECEIPI'M WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
hereby
❑ ] affroomet l haveaanificate nfconm ol m
uto -heam, acenifiente of FIXTURES-PER TRAP -RECEIM'p
Workers'Cnnq+onsaion l nsurance mucenifed copy lbercnf(Sce.38W,Lnb CJwhiehPARK HE Y N
rx all employee',under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECE1111'X
Policy X BUILDING DIVISION FEES
Company GAS-EA,.SYSTEMOVER4 DA) PLANCHECK FEF,
❑ Certified copy is hereby famished. zlp
❑ Ccnificd copy is fled with the city inspection division. GREASEnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS I-ME
COMPENSATION INSURANCE
(ITissatien sad not bccomplctM if the pcnnit is forma,hundrcidullaot(SIM) SEWER-SANITARY-STORM EA.200IT. iN1iRGY FEE
or less.)
I ccs lfy that int he performance of he work for which this .it is issued.)shall WATER HEATER W/VEXGDELECTR
not employ any person in any manner so as to hecome subject to the Worker: AID
Computation Lowsof Celifomia. Date WATER SYSTE%VTREATING Date Retrains
Z Z Applicant NEWRESIDENTIALPLMfT SQ.FT. TOTAL:
Z Z NOTICE,TO APPLICANT:ILafmr making this Certificate of Exemption,you should
f" .N. became,subject to the Workers Compensation provisions ofthe Labor Coda you must
� , forthwith comply with such provisions onhie permit shall be deemed revoked BUILDING FEE
2 ��
0. r� CONSTRUCTION LENDING AGENCY SEISMIC FEL
z Ihereby affirm thatthem is a construction lending agency for the Performance of TOTAL ELECTRIC FEE
the work for which this permit is issued(Sec.3097 Civ.C.)
L) O
Lender's Name PLUMBING FEE
u' F Lender',Ad dress QTY. MECHANICAL PER MIT FEE
U 1 certify that I have mad this application and state that the above information is MECIIANICAL FEE
c..t.lugae to comply with all city and cuumy ordinances and stem laws rtleting to PERMIT ISSUANCE
F' buildingemcnowtion,and hembyautbmme mpmecntativesoftKisciry toenmr upon the CONSTRUCTION TAX
J Z above-mentioned property forimpectiun purposes. AUTER OR ADD TO MECII.
(We)agree to save,indemnify and keep hamtless the City of Cupertino against
Iiabllidcs,judgment,coxt and expenses which may in any way accrue agaimtsaid City AIR HANDLING UNIT(TO 10,000 CFM)
rrruuuuuu flyyy grvmi/npaa��t,RTyyy/,,� perms.
mconseuysncc�, " rs's—n ;p � AIR HANDhING UNIT(OVI3R IO,000 CPM)
Signature of AkppplicanVCo mentor Date EXHAUST IIOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE ((EATING UNIT(TO IOTOW BTU) Data Receipt#
Will the applicant or future building Occupant store or handle hsaardous material HEATING UNIT(OVER INION)BTU) TOTAL:
as defined by the Cupcninn Municipal Calc.Chapmr 9,Q.and the Health and Safety
Cock,Sesumi 25532(q? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will then limn....fulam building occupant lordevais whichcmit BOILER-COME(3HP OR IW.WO BTU)
pp g he 9u.Air
huroJmos air cmmmninums as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 1 W,WO BTU)
. Dis n?
❑Yes 0 N NEW RESIDENTIAL MEC({. SQ.FT. PAID
I have read the hmurdous materials requirements under Chapter 6.95 of the 1�
Califomiu l lcalth&Safety Code.Semens 255(15,2.5533 and 25534.I understand that
tithe building does not currently have a tenant.that it its my responsibility to notify me Jut ` 8199
occupant of the requirement which must he met prior to issuance of a Certificate of
Occupancy. V/�
II Y
Ownerorauthufimd agent Date 'TOTAL: ISSUED IIf_