25390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING—E7.TMW AL PERM['I'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, n C Q (�O
]BUILDING DIVISION BUILDING PROJECT IDEN 'O
TIFICAON L J J J
BUILDING ADDRESS: ,�]�_ SANITARY NO. APPLICATIONSUBMITTALDATE
O !1 / ObuVs UNIT# LOT Is
CONT ACI R'S NAME: LIC O
N/C CON"IKOL#
OA CHiTEQ'/FNGI 7HR: LIC NO: DD W�G( Sa ❑
CONTACT. PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT f%UNX MECII
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GKz I hereby affirm that l um licensed under pmvisionsof Chapter9(e mmencingwith JOB DESCRIPTION
a02 Section
d'lorc] of D,nx�onaof the Post and l'rOfc�sionr`ude, my lirensein In PANELS ♦ Al
FzW LicenseO^w UPT0200AMP5 L (/1�4 U !///V/
y Q C Date Commc201-1000 AMPS
F—yZ ARCiII'ffiCTS DEbARA I N SQ.EI'.FLOOR AREA S/SQ.Fr.
�oo I understand my plans shall be used as public records. OVER IOIXI AMPS
rntJ SIGNS ELECTRICAL t
5_
QyJ Licensed professional 'V
�yedQ OWNER-BUILDERDECIARA'fION SPECIALCIRCUIT/MISC.
Eowu 1 hereby uffirm Not I em exempt from the Contractor's License Low for the
m3ay following reason.(Section 703 L5,Business and professions Core:Any city or county TEMP. OR POLE INST.
X40; which rtquims n permit m toxone,,educt,improve,demolish,or repair any vacation,to
to its Issuance,also re the licant forsuch ttofileasi dstatementthat he POWER DEVICES O/
t,K
prior quires pp Penni gee
Op 9(comancinudpith Sectioursuant b")ofDthe ivisisol the Contractor's License Law(Chapter
SWIMMING POOL ELECTRIC ~ L VAL TION
deo 9that he
(commencing pttSection]00)oe basis
sisior thea Need exemption.
Business and Professions Code) h
W=m oMaheiim 31.5 by nheefmmand the ba—fo objects
ectshed exemption. civiny l
of OUTLETS-SWITCHES-FTXTURFS Vs/
�ZG out mmth 7031.5 by any hundred
dollars($50T. suM1jens the applicxnno ecivil penalty of
5 � ani more than live hundred Jnllars($5(10). NEW RESIDENTIAL ELECIR _SQ,Fl. STORIliS 'fYl'F;CONSTRUCTION
z o ❑ I,azownerofthe prnpcny.ormyemployeeswith wagesnsthcirsolecompensauon,
will do the work,andthesrucmre isnot]ntended oraffemlforsele(SaJOM,Business
and Prssfessions Code:The Contractor's License Law does not apply to an owner of
property whomildsor impruvesthercon,xndwhodoex such work Wmsell orthrough his
employees,lding riOntsuchim is sold it areoat intendedmoffered forsale.If.
OCC.GROUP RES.UNITS
however,The building or improvement is sold within one year of completion,t r- TOTAL:
builder will have the harden of proving that he did not build or improve for purposeur,rea of
sale')' PLUMBING PERMIT FEE h1.00D'(,t)Nii APN
[:] I.asowneroftheprnpeny,amexclusivelyconv ctingwiNlicensedro.t.tonto QTY.
consumer the Project(Sec.7044.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
Limits,Lawdoes not apply to anownerofFropeny whobuildsor imprH
ovesereonan
. d I
who contracts for such projects with neommetor(x)licensed pursuant to the Contraetore
License Law, Al,I ER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am escrepr urem Sec. ,B&PC for this msson OEM51DIs FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dote RECHIITT#
WORKMANCOMPIivsAT10NDECLARATION DRAINS-PLOOR,ROOE AREA,COND. SCHOOLTAX Y N
Thereby affirm that l have a cm formsof consent o self-inume.or a certificate of FIXTURES PER TRAP RECIJPT9
Workers Compensation insurance or certified copy thertop5ec.3900.Lab C.)which PARKIFE Y N
cov alPolicyp CH
employ xuaJcr'h GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.IVISI #
FE
44iinA BUILDING DIVISION ES
Company GAS-EA.SYSTEM OVER 4(FA) PLANCHECK FEE
❑ $$YYnrtiOed copy is hereby hundred.
I'Crmifird copy is filed with the city inspection division. GREASEINDUSTRI,WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OF ENJEMPHON FROM WORKERS' GREASE TRAP SOILS FEET,
COMPENSATION INSURANCE
(This section need not becumpleuedtribe permit is for one hundred dollars($IM) SEWER-SANITARY-STORM EA.200FT. ENERGYFEE
or less)
I certify drum he performance ofthe work for which this permit is issued,l shall WATER 11iATER WNENT/ELECTR
not employ any person in any manner w ns to became subject to the Workers PAID
Co,pensaiov Lawsef Culifmmia. Date WATER SYSTEM/BEATING Date Rtteipt#
Oz Applicant '
Z Z NOTICE,TO APPLICANT.IC ager making this Certificeo of Exemption,you should NEW RESIDENTIAL PLMB. SQ.I7. TOTAL:
become subject to the Worke's Compensation provisions mfthe labor Cale,you must
7 forthwith comply with such provisions or this permit shall lx deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thin here is a construction lending agency for the pnfmm ince of
U 0 the work for which this permit is issued(Sm.3097.Civ.C.) TOTAL: ` ELECTRIC FEE
W r Lender',Name PLUMBING FEE
F' Lender's Address QTY. MECHANICAL PERMIT FEE
0 V I certify Nm 1 have read this application..it state that the above Informaian is MECHANICAL FEE
}s coves. Iaproxwomplywithallcityandcounty ordinances andsote laws relatingto PERMIT ISSUANCE
I-" building Construction,and hereby authoriu representatives ofthis city to enter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection mpvcs. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep burmless the City of Cupertino again,
liabilities,judgmeds,tests and expenses which may I.my way accmexgdns,said City AIR HANDLING UNIT(TO 10.00 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,0110 CFM)
Stimulate of AFPlicanUCommetor Dun, EXHAUST FOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,000 BTU) Date Beer tin#
Will the applicant or future building occupant store or handle broadens material HEATING UNIT(OVER 10.000 BTU) TOTAL: ti
as defined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Code,Section 25532(x)] VENTILATION FAN(SINGLE RPSID)
❑Yes ❑No
BOILER-COMP LIMIT OR 10,0(111 BTU) ISSUANCE DATE
Will
us air
eco mnrmfumre building by the
Area Air
Quality
<Manage ant q� Q
ED
Serardom sir wntaninme u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10,000 BTU) sI
lixtrict
Cl Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. �O�• (� 1993
mi
I have d he hamrdom mareriala requirements under Chapmr 6.95 of the \V1 (d V
Califomix Health A Safety Code,Sections 35505,25533 and 25534. 1 understand that tt 1 p ass 111V
ifine funding docent currently have a from,,The,it ismyrcspomibibty to notify the Uf V
f be re airememrx which oras e e m if more of a Cenificae of
1 11-YS-43
Owe t uuthorixeJ ag t Date TOTAL: ISSUED BY:
OFFICE