25906 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C§jER:
PERTINO It ILDI .,h.LCIRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /A /1 O/�
DIVISION BUILDING PROJECT IDENTIFICATION L �9 Y6
BUILDINGSS: /� /� SANITARY NO. APELICATIONSUBMfITALDATE
LALUNIT# LOT#OPHONE: CONTRACTOR'S AMG: LIC NO:Coot g- c kric 5 N/cCONTROL#
AEER: LIC NO: ADDJE55'.1 Al PO
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDGEyePLUh ITCH
PERMIT ISSUANCE ��t.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IDH DESCRIPTION
tupy.� I hereby affirm that l am licensed underprovisions of Chapter9(commencingwith
F00 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS Lt \(f�/N}4►,/Y
QV F full force and effect. ( �,
FZtu License Class Lic.# UPT0200AMPS
vsQdDam Commem, 201-I"AMPS
•• 5/SQ.FT.
yu ARCHITECT'S
S DECLARATION OVER IgAMPSzO
cz—r) lundermand my plan ikdl be usrdpublcrccordsI. L
�11
p y�:W SIGNS ELECTRICAL
E:Cwu lieutxe4 Professional ,1 e,l 1�/ ��
c' d' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. .Y u V ll3
KO a0 1 hereby affirm that 1 am exempt from the Cont actors License Taw for the
Wl :M,o following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F�Oce; which requires a pewit to mtnwa,ahec improve,demolish,or repair any swcwrt DArE
�VY7 prior to its issuance,also requires the applicant for such permit ro file.signedsatemrnt POWER DEVICES
,tCaoC that he is licensed pursuant to the Provisions of the Contractors License Low(Chapter SWIMMING POOL ELECTRIC
d LoW 9(commencingwith Section 71100)of Division Softhe Business and Professions Code) _ VALUATION
W❑y or that he is exempuhcrcfrom and the basis for the allcgcJ exemption.Art,cmanonof
FZJ- Section703156y wry.applicam fora permit subjects the npplicam toacivil penalty of OUTLETS SWITCHES-FIXTURIiS 2 #.
not more than five hundred drif.,(SSW). V
fi=t] nNEW RESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
C F_o ❑ 1,usownerofthepropcny.ormyemplmyeeswiN wages as thcvsolecampcnsatian,
yj
2_2 willduthework,and the structure is not imcndedaroffered forsale(Sce.7(44,Business
and Professions Code:The Contracmrs License Law does not apply to an owner of
pnrpcnywhobuildsorimproves Nercmgand whodues such work himselfor through his OCC GROUP RFS.UNITS
owiemployees,provided thatiuchimprome
vcnts menot iniendedcroRerW foraale.IL
however,the buildingor improvement is sold within one year ofeomplimon,the owner-
builder will have be burden of proving that he did not build nr improve for purpose of
.ale.).
❑ 1,asownerofthcpropenyamexclusivelycomractinywithlicensedcontr.nms to QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
construe the project(Soc.7614,Business and Professions CWk:)The Contractor's
License lawdcesnot upplYhi annwnerofproperty wM1nhuildsorimprovesthereomand PERMIT ISSUANCE /'
whocomicts for such projects with aconametor(s)licensed pursuanuo the Convectors ALTER-DRAIN&VENT-WATER EA
License law. f ) FEESUMMARY
❑ 1 am exempt under Sec. .B&P C for this mason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affirm tM1mlhnvcacenifcate of consem to stili-insure,oracenifi<am ofFIXTURES-PER TRAP !. RECEIPT#
Workers'Compensation lnnumnce or a certified copy therctd(Sce.38W,Lab C.)which PARK PEE Y N
cavern all employee',under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# J BUILDING DIVISIO
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEEitsC) Cenified copy is hereby famished.
❑ Certified copy is filed with the city inspection division, GREASFANDUSTRL WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE'I'RAP SOILS FEE
COMPENSATION INSURANCE
(Thixxection nc,,laa M:um:plened ifthe permit is intone hundred dollaa($100) SHWER-SANITARY-STORM EA.2001T. ENERGY FEE
oT lens.)
I cerify that in the peituwance of the work torwIt It his pewit is issued,l shall WATER HEATER W/VENT/ELECTR
nut employ env person in a y mam:et so n object to the Workers' PAID
Cnmpensati fC I'<.ni an- WATER SYSTENVTREATING Dae Receipt#
O Z nppli<ant '� .
Z � NOTICE.TO APPLICANT:ILafier making this_enificem of Exempuon,you should NEW RFSIDI:N'TIALPLMB. SQ.FT. TOTAL:
F-• V) hensmesabject m the Workers Co.pensaua visinasofthe Labor Code,you most
a 7 fanhwith comply with such provi ons or this it shall be deemedrevoked, BUILDING FEE
W
6s Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
U1 hereby affirm thanhem is a cnnsruction lending agency for the performwce of O the wank for which this pewit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lenders Name PLUMBING FEE
F" lenders Address QTY. MECHANICAL PERMIT FEE
V I certify that I have mad this application and suite that the above information is MECHANICAL FEE
>- UJ correct l agreem comply with Al city and county ordinances and sure laws relating to PERMITISSUANCF la
f-' a. building construction.and hereby authorize rcpresenwtives of this city to enter upon the
LO V LO abwcmimmoncd rt for inspection CONSTRUCTION TAX
property purPises. ALTER OR ADD TO M[Ctl.
gree m cove,iadainnify and keep hamdess the City of Cupenino against
li' esej figments,cases and expemes which may many woyawnaimom at avid City AIR HANDLING UNIT(TO MADE CPM)
e o[the gmmm,of his pewit.
q AIR HANDLING UNIT(OVER 10.000 CFM)Iq
S � ur RApplivanflContractor Date EXHAUSTHOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I X%0W BTU) Dam Receipt#
Wil haP icam or future building occupant store or handle haaardous materialHEATING UNIT(OVER 100.000 BI U)
TOTAh:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health mid Safety
Code,Section 25532(aU VENTILATION PAN(SINGLE RESIU)
❑Yes ❑No
ISSUANCE DATE
Willtheapplicantorfutumbuildingaecupantmseequlpmentnrdeviceswhichemit BOILER-COME UHP OR IW,W0 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality hfaaagemem BOILER-COMP(OVER I W,000 BTU) /
et?
t ❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. PAID
1 have read the h...films materials requiremcros under Chapter 6.95 of the 't
Cahn n.Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that C —9 ��A
if the building docs not curraatime e a moan,that it is my responsibility In nosily the 4
Ocupant of the requirenmms which mus be met prior to issuance of a Cenificute of
ccupancy. t)'Uf ,
Owner or nothomN egem Dae ) ISSUEDB
OFFICE