25590APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPC' RTINO BUIIDIN - ELE TRICAL
APPIACATION/PERMIT PLUMBING- MECHANICAL
BUILDING DIVISION - .PRo3Er.IDENTIFICATION
BUnUdO C
PHRMI I NO.
_ f� [' C O
G J J
B/UILDING AUURESS:
SANITARY NO,
APPLICAI ION SUBMITTAL UATI3
I � N UNIT# LOT#
OWNERS NAME: PHONE:
u, C 7
J/
CON RACTOR'S NAME: LIC NO:
n /� -- /t '��
C� /z1Lai
NEC
E-1
CONTROL#
I RCHRECOUNGI EER: LIC NO:
ADDRESS:
CONTACT: - PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG 17LECIPLUMH MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of CTupter 9 (commencing with
gppL1ANCF.S-RESIDE
JOB DESCRIPTION
P(kNE
UP T< 2 PS
i Section 70(at Division 3 ofthe Busimessand Professions Code, andtny license is in
full fmce and e[fga . ���
I License az Lie.tl� (/df
j Date Common,
2%. 1 P
ARCHITECTS DECLARATION
I understand my plans shall Named m public records.
O iR 1 AMPS
SQ, Ff. FLOOR AREA f/SQ. IT.
SI( :LECTRICAL
'
I Licensed Prnfessiunal
OWNER -BUILDER DECLARATION
P'
'CIAL CIR IT/
I hereby affirm that I am exempt frsnn the Contractors License law for the
TF:MP.M. :R LAW
following crown. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to comfort. alter, improve, demolish, or repair any sometime
prior to its issuance, alsurequires the applicant for such primal to file a signed statement
POWER IC S
j that he is licensed pursuant to the provisions of the Contmion, a License law (Chapter
9(commencing with Section 7000) of Division 3 of the Business and Professions Code?
mount he is exemptnherefmm and the basis for the alleged exemption. Any violation of
Section 703 L5 by any applicant for a,mirit subjects tM1e upplicvmo a ciOl penalty of
not more than five hundred dollars ($500f
❑ I,asuwnerofthepropcny,ormyemploymswithwageamlheirsolecompensation,
SWIMMIN PO ELECTRIC
VALUATION
O
OIITLFTS- ITCtI[S- PI%TURES
NEW SIDENTIAL ELECIR _SQ. FT.
STOR GS
'1'YPI;CONSIRUCUON
will (Sec. flH4, Business
and Professions Code: The Committee's License Law does not apply m on owner of
property whobuildsor improves themon,nnd whadoes such work himselforthmugh his
wnemployees,pmvided that such impmvememts arc not imumdedoroffered forsale. If,
>/
OCC GROUP
RES. UNI'T'S
�" n 1�TOA
however, the building or improvement is sold within one yearofnsmpletion, the owner.
builder will have the burden of proving that he did not build or improve for pwpnse of
1
Js
./ -..' -
QTY, PLI flING PERMIT
sale).-
❑ I, ns owner of the Property,nmexclusivclycnnhuctingwith license)nnurnnmen to
FLOOU ZDNE
APN
construct the pmjmt (Sec. 7044, Business and Professions Code:)'Um Commune's
License Law does not apply man owner of propeny who bei ids or improves thereon anJ
PERMITISSUANCE
who contracts for such projects will, acomrucmgs) licensed pursuant in the Controcum''e
License Law.
gIfTER -GRAIN&VENT - WATER EA
BEA)
PCC SUMMARY
❑ I em exempt under Sea 13 q P C for This reason
BACK FLOW PROTECT'. DP.VICE
1 SI X: FE'S
SANITARY Y_N
RECE I Fif#
Owner Dom
DRAINS - FLOOR, ROOF, AREA, COND.
WORK MAN COMPENSATION UECLARAI ION
❑ Ibereby affirm thmlhavcawnifwteof consent meal(-insure,nn, certi0cme of
Workers' Compensation Insurance or o certified cagy mereof(Sec. 3800. tab C.) which
SCHOOL TAX Y_N
RECI?II"1'#
FIXTURES -PER TRAP
PARK FEE Y N
GAS - EA. SYSTEM I INC. 4 OUTLETS
covers all employer's under this permit.
Policy #
RI.CI:IP1 p
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREASE1INDUSTRL WASTE INTERCEPTOR
GRADING FEE,
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER SANITARY - STORM EA, 200FT.
ENERGY FEE /
(This section need not be completed ifthe permit is for one hundred dollars (81(10)
or less.)
WATER HEATER W/VFNT/ELECTR
I certify that in the performance of the work for which this permit is issued, l thrill
not employ any person in any manner so as to become subject to the Workm
PAID
Compensation Laws of Califomia. Dau
Applicant
WATER SYSTEM/IRIATING
Date Receipt#
NOTICE TO APPLICANT: IL after making this Cenificamaf Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL FLAIR. SQ, FT.
TOTAL:
forthwith comply with such provisions or this Permit shall be deemed evoked.
BUILDING
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
1 herehy affirm thanhee is a construction lending agency far the performance of
TOTAL:
- - -
ELECTRIC FEE
the work for whichthis permit is issued(See3097. Civ. C.)
lenders Nano
Lendrex Address
QTY. ; MECHANICAL PERMIT _ . FEF. -
PLUMBING FEE
I cenify that 1 have sad this application and state Nm the above inform cion is
l agree to comply with all city and county ordinances and stale laws relating to
PERMIT ISSUANCE
MECHANICAL FEErten.
building construction, and hereby authorize representatives of Nis city to enter upon the
above-mentioned .,a, for inspection purse
pos.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmleea the City of Cupertino against
li ties,judgmenatereararce expenseswhichmayinanyway ecruea,,said City
AIR HANDLING UNIT (TO 10,000 CFM)
inqua ofthe gryrying of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature of Ap%plicant/C to mn�s Dau
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT(TO 100,000BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defiecul by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,IX0 BTU)
TAL:
Code, Section 25532(a)?
El Yes C3 No
VENTILATION FAN (SINGLE. RESID)
Will lheappliwntnrfuurte building occupant useeyuipmentordwiceawhichemil
ISSUANCE DA711
BOIhER- COMP(JHP OR I00,000 BTU)
unirdous air contaminants as defined by the Boy Area Air Quality Management
Xstrict'r
BOILER 100,000 BTU)
pp��
PAID
A ,
❑Yee ❑ No
D
��
NEW RESIDENTIAL MECH. SQ. IT.
I have rend the hazaNnus mmeriuls rcyuiremenls under Chapter, 6.95 ud the
Californial mail6eheo Coda nouiuntl 255118morlanti25534.I,r, 6.95 dthat
ifthebuildingdorsnolcurrnllyhavcaicnan611mthismyresponslbllhylonolifythe
Ail
m{%
��/Y'//3
Ocupwq of the requirements which must be t prior to Issuance of u Certificate of
Ome
ccupancy.
V}' L'V%'Q„I`\y
ISSUED BY:
Owner or authorize) agent Dole
TOTAL:
OFFICE