25905 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '-GTRT PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 9 0 5
BUILDING PROJP,CTIDENTIFICATION
BUILDING AIq)RHSS: ' ' /l SANITARY NO. APPLICATION SUBMITTAL DATI
I UNI'TX LOT#
O ERS AM P ON�F: (��( CONTRACTOR'S NAME: LIC NO: l
le "�� ��� +�D U QU�S G s Uq S NIC CONTROLp
�ARCHI'TECI'/FiNGINIiIiIU' IC NO: ADDRESS:
II fel; IINn (3 mss.�a�.o1Z ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Qmz I hemby affirm mat l amlicenaWunderprovisionsof Clepter!)mommenringwilh JOB DESCRIPTION
-100 Section7")of Division 3 ofthe Business and Professions Code.and my licenu is in PANEU
full farce and effect.
1<„ZW License Class LIC.X UP TO 200 AMPS
m<e- Date Compactor 201-1000 AMPS
ZONZ ARCHITCCTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.PT.
O Z_O 1 understand my plans shall be used as public records.
P vs L IB SIGNS FLECIRICAL
<X7; Licenud Professional
2Zya'< OWNER-BUILDCR DECLARATION SPECIAL CIRCUIT/MISC.
kOaU I hereby affirm that I am exempt from the Contractors License law far the
pu34y following mason.(Section 7031.5,Business and Professions Coda Any city or county TEMP.METER OR POLE MST.
which require..a permit to construct,alter,improve,demolish,or repair any stmetem,
CW}:F prior to its issuance.also requires the applicant for such permit to the a signed statement POWER DEVICES
,9<0 that he is licensed pursuant o the provisions of the Con rectoi s License Law(Chapter
9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
w_y or that he is exempt therefrom and The basis for the alleged exemption.Any violation of OUTLETS / Q
F-Z Q Section 7031.5 by any applicant for a permit subjece,the applicant to a civil pcvlry of FIX'IlIRFS lproe
Ep�O not more Nan Eve hundred dollars($5W). NEWRESIDE1,GALELECR S .Fr.
tYC� ❑ Lasowncro the property,ormycmployeeswith wages as theirsolecom,creemon, Q STORIES TYPECONSTRUCTIOP
63— will do thework,and the structure is not intended or offered for sale(See.7094,Business
and Professions QNe:The Contractor's License Law does not apply to an owner of
property who builds or improves themon,and who does such work himadf or through his
own employeea,provided thatauchimprovementsarenotintendWorofferwd torsade.If. 1 C RI .UNI'TS
however.the buildingor improvement is sold withinoneyeare completion,the owner
builder will have the burden of proving that he did not build or improve far purpose of L ailPLJTF :1
sale.). QTY. PLUMBING PERMIT FEE FL APN
consumer the project(Sec,mag,Business and professions Gtde:)The Corson,and
License Luwd)anol eh applytoith-covacrnfprojecrty ctors)whosed ds Formula I.
The Cereogars PERMIT Ig$UANCIi
who mnsf)rsu,hpvrjemswimaconvacnn(s)licensed pursuanuo me Contractor's ALTER-DRAIN&VENT-
DLicenselaw. WATER(LA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTCCT.DEVICE OUTSIDE FEE.
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECF,IPI'a
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affimrthat l have oam.ccate)fc)nseauoself-insure,nrearificateof FIXTURES-PER TRAP RF.CH1Pfp
W)rka.�Comp,n.mi)n lnsarance oruwrifiedc)py mavof(Sea.3H(N1,Lab CJ which PARK FEE Yrov N
r.all employee's order his permit. GAS-EA.SYSTEM.)INC.4 OUTLETS � RECEIPT
CompX BUILDING DIVISION ES
Company GAS-EA.SYSTEM-OVER 4(EA) O
❑ Certified copy is hereby famished. GAS FEC
❑ Cmificd copy is BIW with Ne city inspwtion division. GREASEIINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FliF.
COMPENSATION INSURANCE
(This section need not be completed lithe permit is forone hundred dollars.($IAb SEWER-SANITARY-ST0RM FA.200F1. ENERGY PEE,
)rhos.)
I certify that in the peff....fine work for which this pemrit is issued,ISholl WATER HI? TER W/VENT/ELECIR
trot employ person 'n try mamrtt sou to becomes ars'
PAID
z Coope= f i WATER SYSTEM?RENTING
Applicant ia.I a Date Receipt#
z NOTICE TO APPLICANT:If,after,making this Cenificat ,t option,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTA:
become subjecuoThe Workers Compensation prov sins) eLadu Code,you must
Forthwith comply with such provisions or this permit shall deemed revoked.
Q$ 7 BUILDING PEC
pw, Q CONSTRUCTION LENDING AGENCY SEISMIC ME
p z 1 hereby affirm that them is a construction lending agency for the performance of
V Q the work for which this permit is issued(Sec.3097,Civ.C.) TAL: ELECTRIC FEC
Landers Name
O U Lenders Addmss QTY. MECHANICAL PERMIT FEE PLUMBING FRE
1 occur,that 1 have read this application and state that the above infrnmation is
F4cored Iagrecmeomplywithnlleilyandc)unry ordinances end satelaws rele[ingm PERMIT ISSUANCE MECHANICAL FEE
to building conswetiun,and hereby authorize atmesentstives ofthiscity to enter upon The
V z above-mens ane l property far inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree ve,indemnify and kccp humleu the City of Calton.agaiasr
liabiliti J. emu masandexpenseswhichmaymanywayac eagains idCiry AIR HANDLING UNIT(T010.000 CFM)
torn cc ofo
of is permit.
AIR HANDLING UNIT(OVER 10,(1!0 CFM)
Slgm ore ofApplic m/C unpar. Dem EXHAUST HOOD(W/DUCT)
PAID
IAP DOUS MATERIALS DISCLOSURE HEATING UNIT(T010(,000 BTU) Dam Recciptp
Will the applic Tor'more building occupant stom or handl,hazardous material
as defined by the Cup, Municipal Code.Chapter 9.12,and me Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Section 25532(x)?
❑Yes 0 N r VENTILATIONFAN(SINGLERESID)
Will the applicant),'-Tom building occupant use equipment ordevices which emir BOILER-C0MP QHP 0R 100000 BTU) I$$ C, A I E
• hazardous air conmminums u defined by the Bay Area Air Quality Managem
District? ent BOILER-COMP(OVER 100,000 BTU)
❑YLboildim,
s ❑No NEW RESIDENTIAL MECH. SQ.FT. py
rod the hazardous materials requirements under Chapter&95 of the P A ^ l
Californiaalth&Safcry Code,Sections 25505,25533 and 25534. 1 undersand That
gdoes not currently have a meanl,mal it is my mllordbility m notify mee mquiremems which mail b,met prior to issuance of a Certificate of
allonu,agent Dam TOT ISSUED BIT
0FFICE