25557 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-'MECHANICAL PERMIT No.
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION 25557
BUILDING ADDRESS: SANITARY NO. /APPPPPPLICATIOON SUBE.
MLTAL DAT
22 r s LOT /1 �q
OWN' AME: O CONTR CfOR'SNAME: C`O\NTR�OLp
�; CIfITE /ENGINEER: LIC NO: ADDRESS: ❑
• CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p y�y Iherebyefl.that l am licenseduncho,00isiorraof Chapter9(cornmencing with JOB DESCRIPTION
POOSection7")of Division Softhe Buiness and Predications Code,and my license is in PANELS
C
full force and effect.
c<ZWo<a. Liccnae Clua Lic.N UP T0200 AMPS
rat<y Co. ConTSD 2p1-1000 AMPS
y FONZ� ARCHITECTS DECLARATION OVER 1000 AMPS (\ p �I.II�DOg2-A�R� �rsQ"n'
O Z—O I understand my plans shall be used u public records. li I�'� F ■
�y w SIGNS ELECTRICAL - l t 1fJ
Licensed Professional r
ny wU
OWNER-BUILDER D ECLARATION SPECIAL CIRCUIT/MISC. I, L T E
x�9Oa I hereby df that 1 am exempt seam the Contras Co License law co the
W3coy which following reason.
ermit(Section
to co3L5,Busiuss andmpr Professions Code:in reai city mundaty TEMP.METER OR POLE INST. Q
t E:ON7 which iniisanpermit recants
altar,improve.demolish,in repair anytwcmre BAT
TC) that hor es licensed pursuant
to the
she of the ch Contrrmar's file a Licans,signed statement POWER DEVICES
<C) that he is licensed pursuant to the provisions of the Contracmr'e Liceue law(Chapter
u. C1
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjeco the applicant Me civil penalty of
fS nm more Nun Eve hundred dollars($500). NEW RESIDEN'T'IAL ELECR9 _SQ FI' STORIES TYPECONSTRUCITON
ftp ❑ Lu eranhepropeny,mmyempendedwithwedforsale Sm.compnuation,
L will dodtawons Craand ft:
he Con is not intended offered do s no,apply 7044,Business
end Professions Cade:The Contractor's License law dos no,apply to rt owner of
propertywhos,Idaorimproveschinip andwhodoessuchwed NMaeeorforo e.hie
own employees,provided Natsuchim is mid nm rioneymmnkdoroffemd far ate. r.
OCC.GROUP RES.UNITS
however,Nebatitdingorimprovementishathe thinaneyearofimrove for the comer.
builder will have the burden of proving that he did not build m improve for purpose of TOTAL:
alt.).
❑ Luownmof Ne pmpeny.amexduivelycontrucring wiNlicenxdconwcrmsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7094,Businus and Professions Cade:)no Convector's _
License Lawdoes nm apply 10 sawracrofproperty whobuildsorimprovesdamon,and PERMIT ISSUANCE
whocoatrucks forsuch projects wiNecomractor(a)licensed punumtto Ox Convecto's
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec.k B&P C for thin mason TS
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dan— DRAINS-FLOOR,ROOF,AREA,COND. RECEI"a
• c WORKMAN COMPENSATION DECLARATION . SCHOOL TAX Y N
❑ Iherebyaffam Natihaveacenificamufcor twmlf.insme.ormc FjG teof FIXTURES-PER TRAP RECEIPT
Warkers'Comlwnmtion Insurance at a cenifmd copy Nemof(Sec.3800,Lab C.)which PARK FEE Y N
rs all employee's under Nis permit GAS-EA.SYSTEM-1 INC.0 OUTLETSRECEIPT g
Policy g BUILDING DIVISION FEES
Com y - GAS-HA.SYSTEM-OVER4 MA) PLANCHECK FEE
Centfied copy is hereby famished.
Codified copy is filed with Ne city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section imitator lxcompleted ifthe Permit is for once hundreddollua(SI00) SEWER-SANITARY-STORM HA.200F7. ENERGY FEE
or Icss.)
I certify that in the performance of Ne work for which this permit is issued,ishan WATER HEATER W/VEN/ELF.CTR
not employ any person in any manner so u to become aubjmt to the Worker% PAID
Camoosationiawsof Celifmois. Dam WATER SYSTEMi REATING - DaleRmeiptg
Q z Applicant
z0 NOTICE TO APPLICANT:If,after making this Certifium of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
became subject en the Workers Compennation pmvisiom of Ne Labor Code,you must
forthwith comply with such provisions or this pemtit shall b<deemed revoked. BUILDING FEE
z CONSTD
RUCON LENDING AGENCY SEISMIC FEE
rrrJJJ I hereby affirm Nat them is a construction lending agency for the perfonnenm of T( A ELECTRIC FEE
O Ne work for which this permit is issued(Sec.3097,Civ.C.)
I7.
Leader'.Name
O tenders Address QTY. MECFIANICAI.PERMIT FEE PLUMBING FEE
[T.1 1 certify that I have read Nis application and mile fast the above information is
correct.lagree tocomply with dl city ard county mdNancea artd sum Iowa reletingm PERMIT ISSUANCE MECHANICALFEE
building construction,and hereby authance representatives of this city menterrupon Ne CONSTRUCTION TAX
V z above-mentioned property for iupeetion purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino studio
liabilities,judgments,costs and expenses which may in any way acme against said City AIR HANDLING UNIT(TO 10,000 CEM)
in consequence of the granting of Nis permit.
AIR HANDLING UNIT(OVER 10,"CFM)
of ApplicanUCamEXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO IM."BTU) Date Receipt#
Will the applicant or future building occupant store or handle hesitations material HEATING UNIT(OVER IM.00)BTU) TO A
JO
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)T VENTILATION FAN(SINGLE RESID)
❑Y. ❑No
Will heepplicantorfmurebuildingoecupent useequipmentordeviceewhich emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
huanleaa air contaminants es defined by the Bey Ares Air Quality Management BOILER-COMP(OVER IM."BTU) rs 1 D
•
District?
❑Vea ❑No NEW RESIDENTIAL MECH. SQ.PI'. A
1 have read the"stations materials requirements under Chapter 6.95 of the 'SEP �/
Culil'oddallealth&SdeQy CWe,Swtions25505,25533and25534.Iandersmndthet .( S,w
if the building does not currently have a mmol.Nat it is my responsibility1r9
to notify Ne / 93
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. C//1'ur���s'�i�,.
Owner m i u lmmed agentOne TOTAL: ISSUED BY: lT�tp,/g�RtnM1/al(l�
�FF�