25135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1JUHA51NL'-F.0. PERMITNO.
APPLICATION/PERMIT
CITY OF CUPERTINO PLUMB ING-MECIIANICAI. • 25135
BUILDING DIVISION . -
BUILDING 1PRWFC'T IIJENTIFICA'1'll]N
BUILDING ADDRESS: SANI'1'ARYNO, APPLICATION SUBMITTAL DATE
UNIT It I.OT# 'r—'
L
OW SNAMI:: % PIIONP.: C TRACI'OR'SNAME: LI O:
0 N/C CONTROL#
RCHITECT/ENGINF.ER: LIC NO: >
f
CONT'AC'T: PHONE: 6.Be5 s#t$, ASF.k'S
Q FY,! 'G}. EL•PCTRIC�PERMIT;. • FEE n i',iHUII'DING PERMIT INFO
¢ ` s• �y'r # U BLDG FLECT PLUMB MECH
s�YO ` • PERMIT ISSUANCE 1:1 El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I hereby affirm tharl are licensed underpmvisionsof Chapler9(commencing with
�U00 Seaion]tl00)of Divi&ion3of the Business and Professions Code,and myli«roe ism PANELS
y W I:- full force and effect.
¢UW IA lass Lic.# UP TO 200 AMPS
Dad Contractor 201.1010 AMPS TIC
ZOv z ARCHITECTS DIiCIARATION OVER 1000 AMPS SQ.FT.FLOOR AREA - $/SQ.IT.
OZ-0 I undersmnd my plans shall be,used as public records.
reJ'4j SIGNS ELECTRICAL
Cloned Pmfcssinnnl
OWNER.BUILDER DI:CLARAI'[ON SPECIAL CIRCUIT/MISC.
Wy 0 a F 1 hereby M.that 1 am exempt from the Cmiumen is License law for be
3 W to following reason.(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR POLE ST.
�; FIwhich requires a permit to constmet,alter,improve,demolish,or repair any&lecture
}� priors its Issuance.also reyunres the opplicam forsuch permit file a signed statement POWER DEVICES
WOO that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aixL 9(ommenictng with Sienna]000)of Division 7 of the Business and Pmfessims Code) SWIMMING POOL ELECTRIC VAI❑N7pN
or thatW_m Sectio 7031. by any
sfrmm�t f the buisfonhets dredeslicant n.Any ivil Peation of
4 Sectione03LSbyanyofimenand to bpermit mbjecuthadlneo cantm. civilpendtyof OUTLETS-SWRCHFS-FlXTURES �-
am mire than five hundred dollars($500).
m ❑ I,us ownerofthe t y p y ages ns lh<irsol<cnmpenseIton, NEW RESIDENTIALELECR —SQ.IT.
propmy,ore em to ed toofferS'I'DRIES I'VPI:CONSTRUC,[ON
,3.. will dmhewons and the he Coreia tor's License
Law red
not
apply t oan wivainess
and Professions ons Cale:The Conthereon,License Law docs not apply to an owner of
propcny whobuilds or improves thereon,and whndoessuch workhimselfor throughhis
cnnployees,provideJ thabuch improvememn urcnorinsndnloroffereA Torsade.IL I I loca.CROUP RES.UN11X
howevar,he building or improvement is sold within one year of completion,the owns- !' 'Tp'TA
border will have the burdenofpmving that hedid not build orimpmve forpuryose of - t
sale.). - r
❑ I.asowneroftbepmNny.umexclusivelyconuntingwithlicmWcontmctomto QTY. i ;PLUMHINGP MIT`_ „ 00DZo E APN
construct the project(SIN.7014,Rashness and professions Code:)no CO urroor'e V<
License Law docs not opplytoanownerofproprty whobuilds or improves thereon,and PERMIT ISSUANCE
who umtmecs far such projects with a convnem,(s)licensed pursuant to the Conuanat's
License law. ALTER-DRAIN&VF. -WATER(EA) FEE SUMMARY
❑ 1 ao exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE oUTSID'FEE
SANITARY Y N
Owner —Date— DRAINS-FLOOR,ROOF,AREA,COND. RECHIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ih C.cripfirmnit Insurance acerbic copyfluecof(Snsure,Or sal,C.)which
FIXTURES-PER TRAP RECEIPT#
WOrken'Compensmionlnsurance ma certified copy thereof($ee.3800,Leb C.7 which PARK FEE YN_
covers all empinyee'a under this permit. GAS-P.A.SYSTHM-I INC. OUTLETS RL?CEIPI'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM.OVER 4(G) PLANCHECK PEE
❑ Certified copy is hereby furnished.
❑ "21 Pt-
Certified copy is filed with the city inspection division. GRIASF,/INDUSTRI.WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
(Missectionnced thecompletedifthepctmitisfor onehundreddollars($100) SEWER-SANITARY-STORM IIA.200FT. ENERGY FEE
or les&.)
(c*� h
ce IRaw k ,which Nis csmitis issued,I shall WATER I1HATL'R W/VENTMLF.CTR
nm emaner tohe Workers' PAID
zCompcomia s# WATER SYSTEM/IRFATING Use Rmeipt#
pC) IL after making ITCenificete of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOcl) be omer's Compensation provisions ofthe labor Code,you must, forthwitprovisions or this vernit shill be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued(See.3097,Civ.C.) ID FAL: ELECTRIC FEE
Lender.Name
OfiU Lender.Address QTY. MECIIANICAL PERMIT, FEE PLUMBING FEE
I certify that 1 have read this application and state that the above information is t ' ''
aworm. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
-' fA buildingeonstruction,andbereby,authorize representatives ofthis city toenteruponthe
V Z above memi...dp inspection purposes. ALM-R OR ADD TO MECH. CONSTRUCI'IONTAX
(We)agree to ad nify and keep h less[he City of Cupertino against
Tia "' v Band eswhich a tnaaywayaccmcagaimu.mdCity AIR HANDLING UNIT(TO 111,103 CFM)
in co ce. ranting,, t B&permit.
• a� o3 AIR HANDLING UNIT(OVER 10,000 CFM)
�i 1 v
mens, Date FXHAUSTHOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T0100,IX3 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle heaudous material
as defined by the Cupertino Municipal Code.Chunee 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) mw4-N CG
Code,Section 25572(e)1
❑Yes El No 6 VENTILATION FAN SINGLE RfSIU
Will theapplicmt nrfuwrc huildingmcupunt uxeequipmemordeviceswbich emit
BOILER COMP QHP OR 100,6110 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Asa Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dlstme,
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FI', My D
1 have read the hazardous materiels rcyuircmenB under Chapter fi.95 of the P
Califontie I lealth&Safety Cale,Sesi.r 25505,25533 and 25534. T undemmrd that
if the building does nm currently have a sober,that it is my respnce oiliry a notify[he $py�$
ec upon of the reyulremmets which ion&t be met prion,,issuance of a Certificate of rt/
Occupancy.
Owner or authanW a gent Data TOTAL: ISSUED