25922 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B 1 .- ..- RI AI. PERMIT NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25922
BUILDING AD(DDREIS:2 ���/� SANITARY NO. APPPUCATIONSUBMIGTTA,L`DATE
I d /Jroo 4ee � UNITM LOT#
OWNIiRS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C /// CONTROLp I
�lefc c�
CHITECTIEI4 I EER: LIC NO:^ ADDRESS: ❑
CONTACT: PHONE:
D��/l QTY. ELECTRIC PERMIT FEE BUILDING PERMIT rINFO
-I(/C �J �Z J V PERMIT ISSUANCE BLDG ELECT PLUMB_ MECH/
LICENSED CONRACfOR'S DECLARATION APPLIANCES-RESIDENTIAL tL-�t/ JOB DESCRIPTION T'
0yz, I herebyaflan that lam licensed underprnvisionsti Charts 9(commencing with
00 Section 7001 Division 3 afthe Briamein and Professions Cade,and in,Inc.is in PANELS /
m full force and effect. SY5 4/a UP TO 2W AMPS VV VJ-I q L
QZUZ License Clas .Lie.# 2%5'
0 Date 2/SiV�9U Con 201-1000 AMPS -
hyZ ARCHITECTS DECLARATION OVER 1000AMPS Pa 1x' S 00 AREA $/SQ.FT.
OZN_ I udantand my Plan shell be used as Public records.
rrn W SIGNS ELECTRICAL -1 L --.�- r.�.
...4I Licensed I'mueodonal lll"',��� Ibis
6 OWNER-BUILDER DECLARATION SPCCIALCIRCUIT/MISC.
OaF I hereby affirm Net 1 am exempt from the Contractors License Law for the
3 O mQ following reason.(Section 7031.5.Business and Professions Code:Any city orcounry TEMP.METER OR POLE I ST. DATE
m.] which requires n .it to concoct,alter•improve,dcmalish,car repair any swaum
2 prior to its issuance,also requires the applicant for such permit o file a signedstm
aternt POWER DEVICES
GO that he is licensed puromm u the provision,of the Contractors License Low(Chapter
ddxp� 9(commencing with Sanum 7000)of Division 3 ofthe Businessand Professions Code) SWIMMING POOL FIECTRIC VALUATIONo
W_m onhet he is exempt NertfromenJ the basial«Nc alleged eaemprion.Any violation of aa^
HIDSection 7031.5h applicant for emit subjects the diem to a civil OUTLETS-SWITCHES-FlXT'URE$
a^S Y any aPP pe J PP penalty of 0 Q
t more than Eve hundred dollars(8500).
ttou I n❑ 1,ms nerofNepropeny.ormymployeeswithwagesn,sheirselecompensation, NEW RESIDENTIAL ELECTR _SQ.FI'. RIES TYPE CONSTRUCTION
y3— will do the work.and the structure isnatinanded oroffered fnrsale(See.7044,Business
and Profession,Cade:The Continuities License Law does not apply in an owner of
propertywhobuildsmimproves thercuLand whodaes such workhimadforihroughhis
ownemployces,provided that such improvementame not imendeduro(fend forsale.If. OCC.GROUP RES.UNITS
however,Ne buildingor improvemem is sold within one yearofcnmpletion,themmer- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ Lus ownendthepropeny,amexclusivdycontmning wiNlicensed mntmetonto QT' PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does not apply to a1 owner of property who bu ilds c r improves thereon,and
who comments f«such projects with a communists)Iimmed!pursuant in the Committees
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑
[am exempt under Sec. B&PC for this reason BACK FLOW PROTECT.DEVICE SAID
NITARY Y N
Owner Data DRAINS-FLOORROOFAREA. REcpI"#
, . . .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby of firm that I have n certificate of consent to selfiroure,or a certificate of RECEIPT p
orkna'Compensation Insurance or a certified copy Nereof(Sce.3801 Lob C.)which FIXTURES-PER TRAP PARK FEE Y N
coven all employees under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby fumixhed.
❑ Certified copy is filed with the city inspection division, GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE-OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need and be completed ifthe Permit is forms hundred dollars($1up) SEWER-SANITARY-STORM EA.200FT. ENERGY FEC
or kss.)
I certify that in the performance of the work for which this emril Ta issued,l shell WATER HEATER W/VENT/ELECTR
not employ en anon in any n t 'act ^the Workers' PAID
z Compensation fl s71
P. . are s WATER SYSTEM/IUATING Date Receipt#
Applioom
O NOTICETO I :If ter making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
!/] becomesubj«uo Ne a Compensation provisions of the labor Code,you must
a7forthwith comply with. t previsions or Nis pemdt shell be deemed revoked. BUILDING FEE '/? '�
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that here is a concoction lending agency for Ne performance of TOTAL: ELECTRIC FEE
L-) O Ne work for which this Permit is issued(Sec.3097,Civ.C.)
Lenders Name
Cs PLUMBING FEE
F Leaders Address QTY, MLCHANICALPERMIT FEE
IU I certify Na 1 have read this application and state Nat the above information is MECHANICAL FEE
correct.degree to comply with all city ard county oNinmces end sate lows rclefing to PERMIT ISSUANCE
I"' y building construction,and hereby authorize representatives ofthis city tomer upon the CONSTRUCTION TAX
V abrwe-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Die)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitles.judgmentx,cestsand expenses which may in any way accrue against said CityAIR HANDLING UNIT(TO 10,000 CFM)
in consequrnu of Ne gmnfing of this permit. a
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Appliwnr/Conunctor Date EXIADS'f HOOD(W/DUCT) PAID �a a,,•,C/�
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO 100.000 BTU) b-lDoLre�'� Rxeipt#
Will the applicant or future building occupant store or handle harmdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Cole,Section 25532(a? Z
❑Yes ❑No VENTILATION PAN(SINGLE RBSID)
ISSUANCE DATE
Will Ne applicantorfutum building«cupant useequipmcntardeviceawhichepN
BOILER-COMP(3HP OR 100.000 BTU)
...door air contaminants®defined by the Bay Arca Air Quality Management BOILER ID0,000 BTU)
wicR PAID
❑Ycs ❑No NEWRESIDENTIAL MECH.—SQ.FT.
I have read the haeardon,materials requirements under Chapter 6.95 of the 15 1994
California Hi n ll&Safety Code,Sections 25505,25533 and 25534. 1 understand thnt FEB
c D
if the building does not mormlly have a tenant,that it is my responsibility to notify the �`Lap
cupwt of th ts which t be met Prior to issuance of a enib to of
Disrepair Z 1 4
Owner ora ml agent Date TOTAL: ISSUEDBY.
OFFICE