25169APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO9 '-
PLUMBING
BUILDING DIVISION APPLICATION/PERMIT G -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO .
`+
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
UNITY LOT
1�
[ QRS NAME: PHO E:
CONTRACTOR'S NAME: LIC NO:
NIC
ElCONTACT:
CONTROL#
ARCHITECT/ENGINEER: LIC NO:
DRESS:
A1511 "S44
a,
PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BL ELECT PLUMB MECH
❑ ❑ ❑
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PERMIT ISSUANCE
LICENS CONTRACTOR'S DECLARATION
flocomylahmatlam is nsedunderpmvisionsofC Vter9(commmcingwith
Section 7000).17 Division 3 of the Business and Professions Code, and my license is in
full force cad eff O
License C as LIC. Y
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
y (r��✓xx/xI�Y/V
PANELS
UP TO TOO AMPS
Dme Contractor
201 - I" AMPS
ARCHITECFS DECf.ARATI
I understand my plans shall he used os publi<recoNs.
OVER 1000 AMPS
SQ. . FLOOR AREA
$/SQ. F1'.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CB2CUIT/MISC.
I hereby affirm that) am exempt from the Contractors License Law for the
followingreason.(Secturt 7031.5, Business and Professions Code: Anycityarwunty
which requires a permit to construct, .[air, improve, demolish, or repair any a...
prior to its issuance, also requires the applicant for such Permit to Die a signed statement
-
l
ER
TEMP. METER OR POLE INST,
POWER DEVICES
Nat he is licensed pursuant o the provisions of the Convectors License Law (Chapter
9 (commenting with Section 7000) ofDivision 3 ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
�ATIO
or that he is exempt therefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ Lasawnerofthepropem, ormyemployees with wagesastheirsoleconpensation,
O o. 0 O
OUTLGTS- SWITCHES - FIXTURES "
NEW RESIDENTIAL ELECfR S.FT.
Q
ORI
TYPECONSTRUCTION
will do the work,and the structureisnotintended moffertd Forsake (Sm. 7044, Business
and Professions Code: The Contractor's License Law does not apply to em owner of
`
I
-
propcnywhobuildborimproves themon,and whodoessuchwerk himselfortbroughhla
own employees, provided that such improvements are not intended or offered for sale. If,
OCC GROUP
RES. UNITS
TOTAL;
however, the building orimprovemenl is sold within one yearafcompledoo, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
sale.).
❑ ones Prone,don,Cdlicensed onaucmrsto
amexinss
FLOOD ZONE
APN
the profthe oject (Set. 70 addely
-)Thi
Business and Professions Code:) The Conuacwrs
conswn the oesnot apply to an
Licensetrawdoes pplymamh who Nereogand
PERMIT ISSUANCE
a coreeroperty
such sedpmimpnvee
who commws for such projects witheconracmr(s)licensed pursuantso the Contracmis
License Law.
ALTER
FEE SUMMARY
❑ I an exempt under Sec. , B & P C for this reason
BACKFLOW PROTECT. DEVICE
UTSID FEES
SANITARY Y -N
RECEIPT#
Owner Dam
DRAINS - FLOORROOFAREACOND.
., , .
WORKMAN COMPENSATION DECLARATION
❑ Thereby effnn shetlheve acmifiwte of consem maelf-insure, aracenificape of
Workers'Cin^mpaensetyionpinesorencEeeoIIrna certified copy thereof(Sec. 3800,Lsb C�1.)
SCHOOLTAX Y N
RECE(PTq
FIXTURES - PER TRAP -
PARK FEE YN
which
covers Policy # I.AI X el bdb �t.1 Uit X17' 10. 13
GAS-EA.BYSTEM-I INC.40UTLETS
BUILDING DIVISION FEES
Comfarm H
GAS -EA. SYSTEM -OVER 4 (EA)
PLANCHECK PGE
❑ Certified copy is hereby furnished.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cmified copy is Ned with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Thissection needambe completed iffiepenrut is fortune hundred dollars ($103)
orless.)
WATER HEATER W/VFNT/ELECTR
I certify that in the performance of the work for which this permit is issued, Isbell
not employ any person in any ..or so as to become subject to the Workers'
PAID
Compensation Lawsof CWifonia. Date
Applicant
WATER SYSTEMITREATING
Date Receipt It
NOTICE TO APPLICANT: If, after rtaking this CeniBsare of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, Elf.
OTAL:
become subject m the Workers Compeotiienvisions of lbe Labor Code, you must
forthwith comply with such previsions orr this permit shall he deemed revoked.
BUILDING PEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction leading agency for the performance of
the work for which this permit is Issued (Sec. 3097, Cls. C.)
Lenders Name
TOTAL:
ELECTRIC PEE
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have read this application and spite that the above information is
correct. lagrec to comply with ell city and county ordinances end ¢tete laws relatingto
PERMIT ISSUANCE
MECHANICAL FEE
buildingeonstruclion, and hereby submiu representatives oflhis city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and kap humless the City of Cupertino against
liabilities,judgments, costs andexpeneeswhich may in any way a ccrueagainslsaid City
AIR HANDLING UNIT DID 10800 CFM)
nsegoence ofthegrantingof this
AIR HANDLING UNIT (OVER 10,000 CFM)
-
EXHAUST HOOD(W/DUCT)
PAID
Signature of ApplicmVContmcmr D
- HEATING UNIT (TO 100,0011 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building aecupant scare or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER IW,ODO BTU)
L:
Code. Section 25532(a)7 -
11 Yea 13 No
VENTILATION FAN(SINGLE RE TD)
Will the applicanmrfuwrebuildingoecupant ueeequipmenlordevices whichemit
BOILER - COMP QHP OR 100,000 BTU)
ISSUANCE DATE
ho,srdous an con®minams as defined by the Bay Area Air Quality Management
District?
BOILER - COME(OVER 100,WD BTU)
' ik I D
No
❑Yes CI No
V' P1
NEW RESIDENTIAL MECH.-SQ. IT.
I have read the hazardous materials requirements antler of the
'JUL ea
-
o & Safety Code, Sections 25505, 25533 and 25534.1 understand they
34. l un erst
Cehe buil ing does
ifshebuildinge the
thato is myreance
V<
����
resnotcurrentlybeveust the off enotify
occupam of she reyuirements which nun be met prior [o issuance of a Certificate of
Ocenpanay.
CfIY Ur k. Tr 1
ISSUED BY:
Owner or authorized agent Date
TOTAL:
UrrH;r