25367 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFILTINO n°G-RE. PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL /�5/� /N'7
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION G J J Y6 I
BUI/%G ADfIRESS:.�� SANITARY NO. APPLICATION SUBMITTAL DATE
• UNIT# LOTH Z2
OW NI' AME.: PHONE: CO RACTOR'SNAME' CNO: • ��' """a
//dd LIN/C CONTROLp
16
ARCHI'I ECI713NGINEER: LIC NO: ADDRESS:
,(ALV ❑
CONTACT: PHONE 4 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/O PERMIT ISSUANCE BLDG ELECT PLO MECII
❑ ❑ ❑
-DECLARATION CONTRACTORS APPLIANCES RESIDENTIAL )OB DESCRI ❑ON
004zThereby aflirm the l—licensed underprovisionsof Chaper9(commencingwith
Iv100 a ion]000)of DivisionJof the Business end Professions CWa,and mylicense is in pgNE1S
FC�qS Kim.and effect.
FZW I License Class Id,k UP TO 200 AMPS
m=y Date Commetor 201-1000 AMPS
ZOZN
ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O Z—❑ 1 undersand my plans shall W used as public records.
1=w 1=w SIGNS ELECTRICAL
Q E.J nscA Pmfcssimml
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOiU e 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 W T,o following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
E'u' which requires a permit to Construct.alter,improve,demolish,or mpair any structure T
Sa�PS priorm its issuance,also requires the applicant(ufxach permit o tile aligned statement POWER DEVICES
tyC O that
dwWaSoO' heislicensedpto the provisions of the us License Law(Chapter
9ewith Section 700T Division SofThe
sinessaW RomCWe) SWIMMING POOL ELECTRIC
fII!—',r��✓ E
tion
VgA OW , or that his exempt
immand the basisfor the alleged
elmAny
vofIFZQ Section
7031.5 any
apdPermit subjects the applicantntoecivil psnsttyof OUTLETS-SWITCHES-FIXTURES
not more
than
five hundred
ollars($500). VT Ep.H
�3� 1.azownerofhepropny,ormymployttswithwagaasheirsolecompnsaton, NEW RSIDENIALELft _S 'ITT. IFI_
J-PO_MI-UT10N
will dolhe work,and the structure is not intended proffered forsale(Sec.701 Bmimss
and Professions Code:The Contractors License Law does not apply to an owner of _
property whobuildsorimproves thereon,and whodom such work himxlfonhmugbbis
own employees,provided that such improvements are not intended proffered mrsale.If, OCC.GROUP RES.UNITS
however,the building oriesu ovement is sold within one yearofeempletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
[j Las owner pfthe prppenm
y,aenclusivclycpmmnV
ing with licensed conagpnm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.]044.Business and Professions Code)The Coneacmr's
License Lawdoesnot apply loan ownerofpropsrry whobuildsorimproves thereon,and PERMIT ISSUANCE
who contracts for such projects with a Continuants)licensed pursuant to the Co=ctors ALTER Liana Law. THAT FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UTMER FEIS
Owner Dat SANITARY YN
DRAINS FLOOR,ROOF,AREA,COND. RECEIPT p
-
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affinnthetl have vicenificme ofconsem mxelLinsurt.ora cenifi<ate of RECEIPTN
XTURES-PER TRAP
Wprken'Crmpyee',onlmuhis per nttnifiedcopy tbertoflStt.38W,lab C.)which PARK FEC: Y N
colas ell employee's under this permit.
PoGAS-EA.SYSTEM-I INC.4 OUTLETS. RECEIPT N
company
BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER 4(G) PLANCHIiCK FGE
❑ Cmified copy is bcrehy h
❑ Certified copy is Bled with
the
e cityity
inspection division GREASEONDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIL.SFEE
COMPENSATION INSURANCE
(This senort need not bo completedLthe permit is imam hundred didim,($IW) SEWER-SANITARY-STORM EA.20T ENERGY FEE
orlesc)
I certify that lush.pMurnedeofthe work for which this .it is issued,lshall WATER HEATER W/VENT/ELECIR
not employ any person in any manner so as to become subject To the Workers PAID
Compensation Lewsof Califpmta. Date WATER SYSTENVTREATING Dom Recciptq
C) Z Applicant
Z NOTICE TO APPLICANT:IL after making this Certificae of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
Gn Income subject mthe Worker's Compensation provisions of the Labor Conde,you must TOTAL:
a forthwith comply with such Provisions or this pernil shall be downed revoked. BUILDING FEE
CSA Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
Lender's Name
0 U lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE �—
F17 I certify that I have read this application and state that the above infotmaoon is
correct.l agree to comply with all city and county ordinances and sun laws trading toMALn-RORADD�MECH.
ANCE MECHANICAL FEE
�. (n buildingeonstruction,and hereby authodm represenutives pfthia city toenerupon Ne
U z menti ed pmpwry for inspection puryous. DTOMECH. CONSTRUC ION TAX
a (We)erg c to save,inde o ify and kee• armless the City of Cupertino against
linbilitics.' costsande ez meymorywayacmc ainsts4 CityG UNII'(TO Ip,0B0 CFM).new, t grand it. 7G UNIT(OVER 10,0(10 CFM)gumnrcpf Applicant/C�ammemr DaeGD WDUC)HAZARDOUS MATERIALSDISCLOSURE T(TO I W,000 BTU) Dec Receipt g
Will the appllcam nr furore building nxi'upant scare or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,OW BTU) TOTAL:
Code Section 25532(n)]
El Yes 0N VENTILATION FAN(SINGI.E RESID) ,w
BOILER-COMP3HP OR 1W,000 BTU IS$ AN A
Will the awousantnrfuturc bandied by d, use equipment ordevices Mramchemit ( )
Alfthezardpus air conami�nu az def nW by Ne Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) ���
l DirlrinP W 19
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.lel'. ^ gD
L:7:�
have read the hazardous materials requirements under Chapter 6.95 of the (�� Wr`n I J
mia Hezhh&Safety CWq Stenions 25505,5533 and 25534. 1 undetswnd the bol V
filmuilding does not contently have a state,the it is my responsibility to notify the
m ofthe requlremems which mast be ma prior to issuance of a Ceniticue ofIV
ancy. T
or authmu ml aT Date 'TOTAL: ISSUED NY:
OFFIC