25325 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BI i—TNG-FATTITITICA PERMIT NO.
CITY OF CUPERTINO PLUMBING.MECHANICAL 25325
BUILDING DIVISION APPLICATION/PF,RMIT
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
# LOT - - .0•-/o
: ---Y 3
SNAM : Y fl NE: CONTRACfOR'S�ME: Mas� LIC NO: ///
NIC CONTROL#
e .ARCHITECf/ENGINF. R: LIC NO: ADDRESS: 0
CONTACT: PHONE: BUILDING PERMIT
y��Q �, , {ry1� �'/77 �/I QTY. { ELECTRIC PERMIT .FEE-
1 1e.s ' 9 N--Y� 3 / /— S � PERMITISSUANCE
BLDG. SLOT PLUMB MOI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
®tyz TOB DBSCRIPf1ON
I hereby affirm that l am licensed under provlslonsofChVwr9(commencing with -
recess,is In PANELS
F00❑ Section]000)nf Divisinn3 e[rM1e Rosiness and Pro[eseions Code.anJ my
y W U full force and effe - e
Nzty LicaruClass Lic.# 39n UP TO 200 AMPS C ,r
4 Dare CmmVva r neat P��NYI 201-IBM AMPS
a so Z .ARCHITECTS DECLARATION OVER UNIT AMPS SQ.FT.FLOOR AMA E/SQ.FT.
Z O m— I understand my plans shall be used as public records.
ti a SIGNS ELECTRICAL
Licensed Pofmsional -
CK� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O a V I hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 W
an following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O¢ which reyuires n permit m cnnstrum,alter,improve,demolish,or repair any swcwc t
�W¢� prior to its issuance.also requires the applicant for such permit to file a signed smmm<m POWER DEVICES
the,he is licensed pursuant t.the provisions of the Contractor's License Law(Chapter
mqx�y� ommSWIMMING POOL ELECTRIC
Wo 9(conem,with Section7000).f Division 3 ofthe Business end Professions Coda) VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of O
trY Section by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES;FIXTURES ,Z 7�F
mCG not more than five hundred dollars($500). p
� [I1,asowneroftheproperty,ormyempleyeeswithwagesmtheirselecompensation, NEW RESIDENTIAL ELE 'f RIE IYPECONSTRUCTION
y will dothework,aadstructurals
the not intaodedoroffered foce
rsale(S .]044ss,15cam "
and Professions Code:The Contractor's License Lew does not apply m as owner of O
propetlywhbuildsorimproves thereon,and whdces such workhimselforNmoghhis
employees,provided that such improvements are notimandedaro(fend torsade.If,' C .UKjF RES.UNITS
however,the building or improvement is sold within one yearofcomplmion,rhe owner-, TAI
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownmof the property,amexclusively contracting with licensed contmetorsto Qom' s PLUMBI MIT FEE . FLO NE APN
construct the project(Sea 7044,Business and Rofessimts Code)This C.nmamm'e -
LicenseLawdoesnotapplymanownerofpropertywhobuilds.,improves thereon,end PERMIT ISSUANCE
who contracts for such projects with aconmorms)licensed pursuant In the Commoners
Licene ALTER-DRAIN&VENT-WATER(EA). 'FEB SUMMARY
s
E) 1 xLaw.in exempt under Sec. ,B&P C builds reason BACK FLOW PROTECT.DEVICE U I SIDE FEES
SANITARY Y N
Owner Date - - RECEIPT#
DRAINS-FLOOR,ROOF,AREA,CORD. -
WORKMANCOMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Thereby affirm Natlhevaacertiftceteof consent to self-insure,ern artifcate of FIXTURES-PER TRAP RECEIPTp
Workers'Compensatioo Insurance or a certified copy Thorned(Sce.3800;Lab C.)which PARK FEE Y N
cover,all I yy��r�car ' prtnit. _ GAS-EA.SYSTEMLE
-IINC.4OUTI'S RECEIPT
Policy# �YL}fJ` � - BUILDING DIVISION FEES.
Company (/.LIS:L dl' GAS-EA.SYSTEM-OVER 4(EA,) PLANCHECK FEE
/rs'k��' CenifeA copy is hereby famished.
Certified copy is filed with the city inspection division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE _
(This secticomi active completed ifthe permit is for one hundre]dollms($100) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or Toes.)
I certify that in the perfotmunce of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any matmer so es to become subject to the Workers' PAID
Compensation Laws of California. Date WATER SYSTEM"FATING Dale Receipt is
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FLATS. SQ.FT. TOTAL:
rq become subjecto the Worker's Compensation provisions of the Labor Code,yon most _ '^
forthwith comply with such Fri......his panni,shall be deemed revoked. BUILDING FEE
Iia is
Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE is
1 hereby affirm that there is accentuation lending agency for the pertarmance of
U O rho work for which thiopato i tis issued(Sec.3097,Civ.CJ - TOTAL: ELECTRIC FEE
Leaders Name
�" ~F Lender's Address - QTY. - .MECHANICPE
_AL RMIT' � FEE PLUMBING FEE ,
U I enmity that I have read this application and state that the above information is MECHANICAL PGE `
r'" a cored l agree to comply with all city and county ordinances and state laws calming to PERMIT ISSUANCE
building construction,and hereby authorize representatives ofthis city to enter upon Na CONSTRUCTION TAX -
UOZ above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
'litiev,judgmems,costs sod expenses which may in any oyacern,against said City AIR HANDLING UNIT(TO 10,000 CFM)
nnseyuenca of rho gmn �c'ernil. �
C AIR HANDLING UNI'P(OVER 10,000 CFM)
Sigmnmeof Appllwnt/Contactor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO FELLOW BTU) Date Receipt#
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(OVER IW,UW BTU7 TOTAL: 31.5
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Coda Section 25532(a)1 VENTILATION FAN(SINGLE RUNIC)
❑Yes ❑No
ISSUANCE DATE
Will thenpplicantorfuturehilding owupentuseequlpmntordeviees which emit BOILER-COME(THE OR 100,000 BTU) PAID p IT
w
hazardous air nmminums as defined by the Bay Area Air Quality Management 100,000B
District? BOILER-COMP(OVER 'TU) - T /1 V[I1 Yes ❑Nu NEW RESIDENTIAL MECH. SQ.FT. SEP + O W3
1 have=it the bazmdous materials requirements under Chapter 6.95 of the
Cxlif.r iSHeallh&Safety Code,Sections 25505,25533 and 25534. (understand Nat /�
if the building Joea nut currently haveetenenL that it is my resprmsibillty to notify the CII Ib
Uf 1/U(Cr "Illu
occupant of the requirements which must be,met prior m issuance of a Certificate of
Occupancy. -p ifs rKV#. ^
OwnermauOodiredagent Date TOTAL:. ISSUED BY'. 5 V �I