25802 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOI ,L TRICAL PERMIT NO.
BUILDING DIVISION APPLICATION�PERMIT PLUMBING-MECHANICAL 25802
BUILDING PR(3JF.CT IDNNTIFICA'f10N
BUILDING/ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
55 UNITp LOT �1 _ J,�,i/It
OW NE NAM PHONE: CO R CTO LIC NAME: LIC NO: \��t Y�
N/C CONTROLM
RCHI /ENG EER: LIC NO: — A DRESS: ❑
Gel^^s
CONTACT: Pxoee: ZITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El .� 1:1LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
�
rLZ
hereby affirm that lam lioenelicensedunder provisions of Cheplx9(mmmencing with
CO Seetion)000)af Division3of the Business and Professions Cade,and mylironse is in PANELS
Lie, Cla sof e. UP TO 200A PS
Dal Contmcter 201-I(N10 Pg _
ZOrmir Z..1 A HITECT'SDECLARATION OVER IOW MP ' I p ` SQ.FT.FLOOR AREA $/SQ.FT.
O Z" _I-uunders�tand my p1 I all as public records.
!/ .�i�9l�iG16f' 0 SIGNS EIE 1 AL4 l
4�mm¢ 'C ane OWNER-BUILDER DECLARATION SPECIAL C CUIT/MISC.
eKOyF c .I hereby affirm Chas I am exempt from fie Consmcmns License Lew for the �11��,+�'�'``��
In3Orn
following re v.(Semon)031.5,Business and Professions Code:Any city or county TEMP.ME ;R OR PsOAi
m-¢] which requires a permit m construct,after,improves.demolish,m repair any,partum _
Nn}2 pronto its issuance,also regmms the applicant for such Permit to file a signed statement POWER DEVICES
p iy <p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
L o�' 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC �s ///+.. VALUATIO
-,y or that h70315 mpnherefroandant f the permit sbjeallegedexempn to civil
of OUTLETS-SWITCHES-FIXTURES / r� �/1
Section)031.S by any applicanI.a($permit subjects the applicant to a civil penalty of L�.Jed
not more than five hundred donors($Sm). NEW RESIDENTIAL ELECTR S FT.
❑ l,asdo the
work,and hestreny,e is not ended or
forsalei(sole compensation, Q' STORIES TYPE CONSTRUCTION
L will dothewon,andch'Une Com not mended Law
does
apply to on
ss
of
and Professions Code:The Conpomons License Lew such
not apply lf an owner of
own
property who builds provided mprovesih imp andwhodoessuchworkomselfedforaghhis
employees, inori improvement
hlmprovld whin meyelendedmplfend the own If, OCC.GROUP NES.UNITS
however,the buildingorimprovementissoldwithinoneyear ofimproe fo,theownm-
bale.). will have the burden of proving that he did oat build or improve for purpose of
sale.).
❑ Las the Ito
.(So, 044,Business
ss an contradsion, We:)The C srmmrs to QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
Licenseconstruct the projxt(Sec.)044,arra as and Pmfexsiuns Code:)The Corsicans PERMIT ISSUANCE
License Law does not apply toanownerofproperty who builds
rs improves thereon,and
who contracts.Law.for such projects with a contractions)licensed pursuant to the Convaaons
' License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date RECEIPT N
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby afmsmthat lh u ecor.o ifie oonsrnurof(Sits.380(Lab C.)c which
FIXTURES-PER TRAP RECEIPI'k
Workers'Compensasionlnsurancc oracenieed copy thereof(Sec.3g00,Lab CJwhich PARK NEE YN
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy H BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
'❑ Certified copy is Bled with rhe city inspersion division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forone hundred dollars($]W) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I rectify that in the performance fshe work for which this permit ishooted,I shall WATER HEATER W/VENT/ELECIR
not employ any person in any manner so as (kersPAID
O 7-. Ao ices canon li m ! /L+i WATER SYSTEM/TREATING Date Receipt#
PP rood
NOTICETOAPPLICA T:If,efte akingthis Certificate of Exemption,you should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
0 hcome subject m the Worker's Compensation provis m vdthe Labor Code,you must
forthwith comply with such provisions or this permit shall b,deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of A ELECTRIC FEE
L.) O the work for which this permit is issued(Sm.3097,Civ.C.) L C6 7S
W. Lender's Name PLUMBING FEE
Lender's Address QTY, MECHANICAL PERMIT FEE �-.
VI certify that I have read this application and state that the above information is
W comm.Iagree lu eomply with all city andmarty ordinances andslam laws relating to PERMIT ISSUANCE MECHANICAL FEE
R
buildingeonsnuction,and hereby authoriac representatives ofthis city to enter upon the CONSTRUCTIOFEE
L) z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
N TAX
(We)agree to save,indemnify and keep harmless the City of Cupenlao against
liabilidesjudgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT G70 10,"CFM)
in consyquence of the gremin of permit.
AIR HANDLING UNIT(OVER 10,00)CFM)
Signature of Applicant ontmctor ate EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001)BTU) Date RxeiptN
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER I W,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Coda Section 2553200? - VENTILATION FAN(SINGLE RESID)
❑Yes 13 Noso
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will air
acont a contaminants
s.1 building by the Bay Am.ou,nAenmuality es Managemch ent
1 1D
•
Di
mdnos air conmminenta ee defined by the Bey Aree Air Quality Monegemenl BOILER-COW(OVER 100,000 BTU)
DisMc@
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ����
1 have read the Inanition.materials requirements irets under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534.I understand that
if the building does not currently have a tersol,that it is my responsibility to notify the ccupant of Ne rMu nements which must be,met prior to issuanceofa Certificate of
Occupancy. CIIlUr�;v
Owneroreuthoriaed agent Date O E: ISSUED BY:
OFFICE