25986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUn:DTNG-RI;F,,'kl A, PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /] 5 (� O
BUILDING DIVISION BUILDING PROJFICI'IUENl H ICAI]ON L J J o
BUILDING TyA�DDRESS: SANITARY NO. APPLICATIIO�NsulymnTAL DATE
KVIII /0 -1/0 / UNIT# LOTH I YTG
OWNERS NAME: PHONE: CONTRACTOR'S NAME: 3'Fs LICNO: NlC CONTROLN
6 B, Tkrw S o 3 J C" rn# oN (0x3
RCHIIECINGINEF,R: LIC NO: A KESS: CL— ❑
Ll O M o \l
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
'7[ / BLDG ELBC9' PLUMB MECII
E L eo Aj J + /9� PERMIT ISSUANCE 0 F-1 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN'1'IAl.
LOB DESCRIPTION
nyz Ihemby affiant had l am licensed underprovisionvd Chnpler0(enmmencie"ith
PA0W0q Section 7000)of Division Sof the Business and Professions Gxlc,and my license is in PANELS
TUU fall force and effect.
Fzm License Class e24 Lic.N 62sitin UPTO2MAMPS
vs j y Dam J—Y 4,IComrnnnr OV-I"AMPS SQ.17.F E/SQ.I.I.
z fOy7 _ l ARCHITECTS DECLARATION OVER IOOOAMPS epBs
OZ-0 I understand my plana shaft be used as public records.
y F SIGNS ELECTRICAL
Q—f,j Licensed Professional p
��a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I� CI r� T 1
KO W 1 hereby i ffimr rhm I am exempt farm the Contrast License Lew for the uv� GGG V
tvL�y fallowing mamn.(Section 7031.5,Business and Parfessiom Code:Any city or county TEMP.METER OR POLL]NST. D ! t
F sn J which requires a permit to venzwct,alter,improve,demolish,or mpxif any structure
z�}5. prior to its issuance,also requires the applicam for such Permit to file u signed statement POWER DEVICES p TE
)yC00C that he is licensed pursuant to the provisions of the Cor actor's License Law(Chapter SWIMMING POOL ELECTRIC VALUATIOIII/�
nao[� 9lcommerwar"ith Section 7000)of Division 3 of Ore Business and Professions Code) CV
❑N Oflal he is exempuherefrom candidate basis for the alleged exemption.Any violation of OUTLETS-SWITCI HIS-FI%TURES 1
,Z, Section 7031.5 by any applicant for a permiuubjecrs the applicant to a civi l penally of 1 LLL I 66,I_
�_C nen nusrelhan Eve M1undrcd dollora($500). _
� � ❑ I,asnwncrot lhepngscrly.ormyempluyces with wagesaNEW RESIDINTIALELECI'R SQ.FT.
slhcirsolecomper%inion, S'IORIIiS TYPE CONS'1'NUC'I'ION
a3� will do the work,and The structure is not intended or offered lin sale(See.70H4,Business
and professions Code:The Commitor's License Law does not apply Io as mine,of
progeny who builds or improves thereon,and who does such wink himself or through his
employees.provided that such improvements arca intcndedomffefed forsole.If. OCC.GROUP RLS.UNITS
however.the buddingor improvement is sold within one yearoferandetion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sa1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE ANN
❑ I,uawnerofthepmp nXamexclusivelycmn ctingwiNlicens conn comto
cra a ria.the pmjeet(Sec.70H 1.Business end Prefessions Code:)The Conuacmra
License lawdocs not apply toxo ownerofpropcny who builds or Mparveslhereon.and PERMIT ISSUANCE
who contracts for such projects with immossemr(s)licensed Pursuant to[be Coneseemes ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. .B&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-FLOOR.ROLF.AREA.COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
RECEIPT#
❑ ers Coyufnrm Batlihave acenificam ofmnscnt to hcc.f(insu.a0r LOS C.)whichteof FIXTURES-PER'I'RAP
Workars'Cnntpensminn lnxumnecoracertiful copy thaad(Sw.3g(q,Lab CJ which PARK NI?13 Y N
to,cr,all anplolitte q 4jg pr,Tpys GAS-PA.SYS'I'13M-I INC.0 00TLITS RECEIPTN BUILDING DIVISION FEES
Pnityp 5 // '1•
I-] Cny CSIed. GAS-EA.SYS'T'EM OVIiR 4(13A) PLANCHIiCK FEF,
❑ Ccmfied copy is filed wfamished.
❑ Ccnilied ropy is Bled with the city inspection division. GREASFANDUSTNI.WASTE INTERCEPTOR GRADING IIiE
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Mi,section need nal be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM IA.200FT. ENERGY ME
or less.)
I cenif flonm(he performance of the work far which this pcmrit is issued,I shall WATER HEATER WolIIJELECTR
not employ any person in any manner so as to become subjen to the Workers - PAID
Compensation Lawsof Califiona. Date WATER SYSTEM/TREATING Date Receipt is
O Z AptifisiNOTICE m
Z Z TO APPLICANT.If.after m Ing this Certificate of Exemption,you should NEW RESIDENTIAL.PENH. SQ,IT. TOTAL:
rA become subject mthe Worker's Compensation provisions ofthc labor Code.you must BUILDING FEE
> Rsnhw'nh comply with such pmns:ons onhis pennil shallbedeemed revoked.
W r� CONSTRUCTION LENDING AGENCY SEISMIC IEE
z I hereby oflirnuhat them is a construction lending agency lin the performance of TOTAL: ELIiC1'RlC hili
L) O The work for which Ibis permit Is issued(Sec.31191,Civ.CJ
laardcr's Name PLUMBING ITEU" F Lender.Address QTY. MECHANICAL PERMIT FEE
C U I cenify that I have read this application and slam that the above information is MECHANICAL FEE
>� W cnrren.]agree In comply with all city and county ordinances and state laws attuning to PERMIT ISSUANCE .
F' building construction.and hereby mationaa representatives of tris city to curer upon Ne CONSTRUCTION I'A%
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MEC]I.
(We)ugra m save,indemnify and keep harmless the Cay of Cupertino against
liabilines,judgnmms.cosssande Tenses bichmayinanyweyacerueogaina taxid City AIR HANDLING UNIT DO 10,08)CFM)
in ce of the granting thisp tit.
ow�Ten AIR HANDLING UNIT(OVER 10,000 CFM)
gnat ¢anUCuatmcmr Datc EXHAUST HOLD(W/DUCM
PAID
IIALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.8)(1 BTU) Date Receipt N
Will the applicant or future building sx cupant store or handle hawdmus material TO
as def ned by the Cupertino Municipal Cale,Chapter 9A2,and the l health and Safety HEATING UNIT(OVER 100.000 BTU)
Coda Sechon 25532(x)'? VENT ILATION FAN(SINGLE Bps[]))❑yes 11 No
ISSUANCE DATE,
Will the applicant or l'ntummildingoccupunt use equipment ordevices whichetmh BOILER-COMP DHP OR 100.000 BTU)
I h communist I defined by the Bay Arca Air Quality Management BOILER-COMP(OVER Itg),810 BTU)
'District?: air eon am, a ns. F A [ p
❑Yu ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 hum,feud the hazardous mammals mgmearma s under Chapter 6.95 of the Jq{F A
Culifomia I lexlth&Safety CNet.Sections 25505.25533 and 255 W.1 undersuM thm 199
if the building does not currently have a tenant,that it is my responsibibly to notify the f^
rry
occupant of the uiremcnu which must be mel prior to issuance of a Cenm 'iOcaof CITY
r
Oveupaaey. f
Owner or aulhnrimal agent Date TOTAL: ISSUED BY:
OFFICE