25799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1 CITY OF CUPERTINp BUILDING.ELF.CrRIUM PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAI- ^ ^��
BUILDING ADDRESS BUILDING PROJECT IDRNTIFTCAVON 'Ll 1`1J 9
SANITARY NO. AIPIPL_ICAUONSUBMI'I'1'ALDATE
V I 1 LOT# Yl
i.tol I R
CONACfOR'S NAME: LIC NO:
N/C CON TROI,p
•ARCHI _LT/[BJGINEER: I LIC NO: ADDREgg:
CONTACT: PHONE: ❑
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE
BLDG ELECT PLUMB MECH
❑ }�-r ❑
LICENSED fintICONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL 1 ON
Oa'Z Ihcrebyuf Division
i Natl 3-fth Bused inns and isions oro Cotw9(commencing with \ JOB DESCRIfTON
LL100 Seefar iuresandaf Uivis onJnf the Business and Profession Codeaffse, ,wed my license is in PANF3S J
ff ZZpp`�f License Class Lic.p UP T0200 pups
N=vi Dona
_Cc mreator 201-1000AMPS
F-to
ARCHITECTS DECLARATION REA
O2 h G 1 understand my plans shall be mad as public swords. OVER 1000 AMPS
SQ.FT.FLOOR ASISQ.FT.
a`5W
Uunsed Pmlesv.�] onnl SIGNS ELECTRICAL
K
OWNER-BUILDER DECLARATION SPECIAL CIRCUCYMISC.
Mi1 hereby affirm Nat 1 um from me froNe Caricatures License law for Ne
0. follawingreaan.(Section 7031.5,Business and Professions Code:Any citym-ecamy TEMP.METER OR POL
m which reyrin"it Permit to consoum,alter,improve,demolish,or repair any structure I
C � Prior m its issuunce,also requiresNeapplicant for such permit m filen signed miument WER0.DEVICES I
��00 that he is licensed pursumrto the provisions of Ne Connectors I-Reaw law(Chapter
P0.�a,Pa 9(commencing with Section 7000)of Division 3 afshe Business and Professions Code) S IMMING POOL ELECTRIC I '• VALUATION
ro or that he is exempt therefrom and the basis for alleged exemption.Any violation of ^
t:F;Q Sectlon]031S by any applicant Sm.pc mit subjects the applicam me civil penahy of OUTLETS-SWITCHPST T RG
Y,L nut more than five hundred dollars($500),
W�ro ❑ I,mpwnerpf@cproperry,prmY emplpyeeawithwageam@cirwlecpmpemadm, NEW BMIUEdTIAL ELE Q� STORIES
TYPE CONS]RUCr10N
L 3,. will darhe work,and the structure is not intendedoroffered foreals(Scc.'I044,Business
and Professions Cade:The Contractor's License Law does nor apply to an owner,of -
properly who builds or improves thereon,and who does such work hi mae If or through hi s
wnemplpytts,provided Nat such improvemenrsert notimrndcd proffered forests.
If. OCC GROUP RES.UNITS
however,me building or impmvemem is wld withinnneyearofcompletion,Ne owner.
builder will have the burden ofproving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,as owncrofthe Pmpony,amexclusively contracting wish licensed contractors to QTY' PLUMBING PERMIT FEE FLOOD ZONE 00th
wmevuct the project(Sec.7044,Business and Professions Code:)The Con"em,
License Law does not apply to anowncrofprapery whrmilds or improves imlim,wit PERMIT ISSUANCE
who contracts for such Pmjects with uci muutorts)licensed pursuant mthe Conoucmrs
Liccnw Law. ALTER-DRAIN as VENT-WATER(EA)
❑ FF-E SUMMARY
I um eaemPt under Sec. ,B&P C for Nia reason
BACK FLOW PROTECT,DEVICE SID- .I-
Owner Data SANITARY Y N_
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARL'A,COND. RECEIPT
• c❑ Ihcrtbyaffim thatlhaveeeenificete ofconsem molt-insu SCHOOL TAX Y N_
rt.ora eenificam of FIXTURES-PER TRAP RECEIPT#
Workera'ComPcnwtion lnsurancewacenified copy thertof(SecJg00,LabCJ which PARK FFa? yN_
rs ell emFlwit
lnye<'s under this pe .
Palsy# GAS-13A.SYSTEM.]TNC.4 0UTLETS RECEIPT#
Amp BUILDING DIVISION FEES
mified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHF•CK FEE
❑ Cenified copy is riled with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR
GRADING LLE
CERTIFICATEOMPE SATIONEXEMPTION NSURAN WORKERS' GREASE TRAP
COMPENSATION INSURANCE SOILS FEE
(This'""m nal notu<ompleted ifthe permit is foram hundred dollars($11) SEWER-SANITARY-STORM FA.20BFT. ENERGY FEF:
or less)
I certify that in the Perfomance ofthe work for which Nis permit islamed.I shall WATER BEATER WNENT/C•LECTR
not employ any pawn in any mmmer w as m become mbjwt to the Wohen'Applicant PAID
z pmpema on sees of Ca ifomia. WATER SYSTEMTRFATING Date Receipts
NOTICETOAPPLICANT:If,after making this Cmifiwa,of Exemption,you shouldNEW RESIDGNTJAI.PLMB. SQ,FT.
C+ fn became sub!acro the Workers Compsmandion provisions ofthe Labor Cade,you must TO
faMwith comply with such Provisions o,this permit shall be deemed revokes.
_ BUILDING FEE
W A CONSTRUCTION LENDING AGENCY SEISMIC HE ,
z I hereby affirm Nat them is a construction lending agency for the perfcrmwtt of
V O the work for which this permit is issued(Sec.309],Civ.C.) ELECTRIC HE
E Lenders N.
Lewers Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify Wee 1 have read this application wed slaterat Ne above information is
cooacv I agree tu comply with all city and county ordinances and state laws mlating to PERMIT ISSUANCE MECHANICAL FEE
V) building conswction,wd hereby authorize representadvesofthisciy roma,,upon the
U Z muse-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCf10NTAX
(We)agree to save,indcmnif wed k harmless the City of Cupertino Against
Iimililies,judgment"em,sand h' yon way asecruaageinst said City AIR I IANDLING UNIT(TO 10,M)CFM)
nuscyuarceo f n t. r _
AIR HANDLING UNIT(O VER 1RXK CFM)
mmureof Applicunt/Con meter Data IIXHAUSI I IOOD(W/DUCT)
PAID
HAZA ITRIALSDISre orha RE HEATING UNIT(TO IIX),gp BTU) Dam Receipts
Will the the Cupertino Municipal
al C de.C am start or handle haealth a material
rode,Section
theCupertinoMunicipal Cwle,Chapter 9.12,and the Health and Safety BEATING UNIT(OVER IW.000 BTU) TOTAL-
Came,Section 253J2(n)]
1)Yea 0 N VENTILATION FAN(SINGLE RFSID)
Will the upplienate,future buildingoccupant usecyuipmenmrdevireawhich emit BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
havrdeas air contaminants as defined by the Bay Area Air Quality Management
. Domer? BOILER-
COMP OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. A
f be Lb.ildi.,
renal the hozardpa materials regrirenmms under Chapter 6.95 of the a'4
alth&Safety Cue,Sections 25505,25533 and 8534. 1 underslmd the, rs,®�
ue xsnwcurremly haveamnam,etmitis my respoaibil. mnmify NeN 3 1e rtyuirements which must u met prior m issuance ofa Cenificme ofC�1rronzcd egem Date TOTAL: ISSUED BY:_ IJ( J
OF I