25168 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OECUPERTINO 1li ILDING-ILhCTRi AI. PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION RAD)ING PROJECTTIDE NTIFICAI TON
BUILDING ADDRESSs SANITARY NO. ///A'PPPLICAT�ION SUBMITTAL DATE
n UNIT# LOT# /��/TA `�
OWN . AME: PIONE: C CI'OR'S LIC NO: 1 VVV ���••/
_ / NIC CONTROL#
ARCHI'I ECT/ENGINEER: LIC NO: A RESS: ElAV
0is
CONTACT: PHONE:
QTY. ELCCTRIC PERMIT PEE HU TNG PERMIT INFO
BLDG ELECTPLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IORDFSCRIPI'10
Metz I hereby affirm that lam licensed un&rpmvisionsofaapter9(commencingwith
ti10❑0q Semioti700o)of Division3of the Business and Professions Coda and my license is in pgN1i1S ,/I
F�UU fullloce nn°`ffe� Lie.# D3S f4
NLW Lheen:• las CC.� UPT02(N1AMPg
60. Doe Nno-ectnr EZ201-IM AMPS
F yZ RCIII'ITiCTS DEC.A ATO SQ.Fr.FLOOR AREA S/SQ.ET.
zO0�_ I understand my plans shall b,used as public records. OVER IMAM —
g.ytW SIGNS ELECTRICAL ,•-`I I^ ® I N
�Q License.)Professimtxl
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. 4
KOiU 1 hereby affirm that 1 am exempt from the Commandos License Law for she
W
V,C' fellowm"caser.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
( which require,a permit m emanon,alter,improve,demolish,or repair any structure
prior Loin,issuance.also requires the applicant Br such permit to file a signed statement POWER DEVICES
DATE
Lepa1) Norheis Iiciall pmsuammthe)Gf Djansof the Crmractess License Law(Chapter SWIMMING POOL ELECTRIC
W 9(commencing with gection)(N10)of Divisinnlof Ne Business and professions Code) VALUATION
of that he is exempnherefrom and the basis for nh<alleged esemptim.Any violmionof
G Sermon 9031.5 by any applicant fur a penninsuhjecns the p]cam to a cM l penalty of 011'I'LCTS-SWITCHES-FlXTURF.S
not more than five hundred dollws(8500). NEW RESIDENTIAL ELECfR _SQ.Er.
STORIES TYPECONSIRUCfION
ap ❑ Lasnwrk,and epstruct,ormyempended wiNwagaartheir sale cam.Business
3°= will dothenicas and the he Contisnors License offeredsnot apply to am Bulinus
and Professions Cole:The Contractor License Law does not apply no rn owner of
proown employees,
pdaorimprovesch Impr,amdwhn smnotimendehlmselfnmhrooghhis OCC.GROUP RES.UNITS
ownemployees,provided Natsuch Improvementsarenot imrinfroroffctM for sale. r-
however.the building or improvement is said within.,year or improve I.,the owner- T'OT'AL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lns nwncrofthe pmpeny,nm exdusivelymmractingwiN licensed cnnoacmrtu QTY' ;PLUMHING PERMIT PF.E FLooU ZONA nPN
construct the project(Sec.7034,Business and Proferesiom Code:)The Contractors PERMIT ISSUANCE
License Wwdoes not applyto an ownerofpmpenywhobuildsorimprovesthene n,and
whoconwets fur such projects with a counteracts)licensed punuanuothe Com names
License law. ALTHR-DRAIN ar VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this reason BACK FLOW PROI ECT.DEVICE TSIDE F
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA,CONO RECEIITp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
hereby affirm that I have a cenificnne of consent to sel Gimum,or a cedifcate of RECEIPT'#
Workcrv'Cbmpensmirn lreumncc oracmifeJ copy lhermf(Sec.3g00.L.b C.)which FIXTURES-PERI'RAP PARK ME Y N
ersallcmployee's underthispccard GAS-EA.SYSTEM-I INC.4 OUTLETS R[VISI N
Policy N BUILDING DIVISION(FES
C..,.,....,,, a�—
tedcopyisherebyfamished, t� GAS-F.A.SYSTEM-OVER4(GA) PIANCIIECK TGE
LJ CpWCertified copy is filed with the city inspection division. GRFASEBNDUSIRL WASTE IWERCE17OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMP17NSATION INSURANCE
(This section need not the completed ifthe permit is future hundred dollars(SIW) SEWER-SANITARY-STORM FA.201 ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is Ended.l shall WATER NEATER W/VENT/EL[7=
not employ any person in any manner so u no become subject to the Workers' PAID
Compensation Lawsof Califomia. Dole WATERSYSTEM/1'REATING Doe Receipt#
O Z Applicant
Z NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,youshould NEW RESIDENTIAL PLMB. SQ,Ff. TOTAL:
bcmme subject o the Workers Compensation provisions ofthe labor Code,you must
forthwith Comply with such provisions or this pcmtit shall be deemed revoked. I BUILDING IEE
W CONSTRUCTION LENDING AG Mi CY SEISMIC
5 z PfiE
1 hereby afford that hem is a construction lending agency for the Performance of
V O be work far which this .it is isomed(See 31197,Civ.C.) TOTAL: ELECTRIC FEE
w r lender's Name L rethr'a Address QTY. MECI IANICAL PERMIT FEE PLUMBING h1iG
L) 1 certify that 1 have read this application and state than the above information is
1 counter.I agree incomply with all city mW county adjacenciesand same laws relating to PERMIT ISSUANCE MECHANICAL ME
rA building construction,and hemby authorize mpresentatives ofthis city to cmerapon the CONSTRUCTION TAX
V above-mentioned property for inspecium purposes. AL'T'ER OR ADD TO MECII.
(We)ague m save,indemnify and keep hmmless the City of Cupertino spurred
Iiabilinice.judgmems.easns and expenses which may in any way ace gmmtsmd City AIR HANDLING UNIT(TO 10,0110 CFM)
conscyuence of the gnming m permit. A
AIR HANDLING UNIT(OVER 10,01)8 CFM)
Signature of App' m/Con actDate EXI IAUST ROOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(M 100,000 BTU) Data Receipt#
Will the applicant or more building occupant store or handle hazardous material IIIiAI'INC UNIT(OVER 100,000 BTU) T '
as def tied by the Cupen ino Municipal Cole,Chapter 9.12,and rhe Health and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLB RESID)
❑Yes ❑No
Will nheapplicnm orfuturc building occupum use cquipmcnl nNevices whichemii
BOILER-COMP(311P OR I INh000 BTU) ISSUANCE DATE
hicanom us air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dist n?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. PAI
I
I have read the hazardous mmeria
ls acquirements under Chapter 6.95 of the I�
California Ilealthdo s Safety Cola Sections 255115,t it
and 25534. 1 undermaad than r
if the building does not currently have amount,that is is my rtspovibilitymnotify the 819
accupem of the tequircments which mus be met prior to issuance of a Cenifica¢of 9
Occupancy.
Owner orauth sized aged Dam 'TOTAL: ISSUE tY�l� I I Cr YU