25269 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYPERMrr No.
BUIL
XUPDTEDIVISION APPLICATION PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING 25269
DDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
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UNIT# I.OT# G y ta�
O SNA PHONE: a y CO T. 'g NAME: LIC NO:
r ee Q Q .— Sfo - s G is" CONTROL#
ARCHITEUDENGINEER: 7 LIC NO: ADDRES ❑
t ry /
Oro �� L
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BG 'ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S OR'SDECLARATION APPLIANCES-RESIDENTIAL
p1,4Z00 Thereby affirm Berl are of
he Business
and rafievenes Coter9(commencing wiB JOB DESCRIP�QFI
t+]00C Section]IXq)of Division 3 of the Business and Professions Code,and my license is in PANELS K�I
auzU rml force ora erred `ya� l..
ti<W Lem Class - V 9f 13 yZ' _" UP TO 2fq AMPS l�
Q Contractor
1"vOi A HITECI-S DEC TI T 201-1000 Ab1P5 SQ.FT.FLOOR AREA
O
OZ-® 1 trade rsmnd my plans shall be used as public records. OVER 1000 AMPS 7SQ.FT.
rn SIGNS ELECTRICAL
4
Licensed Profesmonal
ff��,
OWNER-BUILD ER DECLARATION SPECIAL CB2CUIT/MISC.
�hpi5mli. I hereby affirm that I em exempt fiver the Convecror'a License Law far the
aq 3O y following reason.(Section 7031.5.Business and Professions Code:Any city monody TEMP.METER OR POLE INST.
m which regmres a Permit to construct,alter,improve,demolish,or repair any structure
NQ2 prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
iy C OC [hat he is licensed pursuant to the provisions of the Comment's License Law(Chapter
p4 cl 9(comnencing with Section 7000)of Division 3 ofthe Businesamd Professions Code) SWIMMING POOL ELECTRIC VALUejy'Ip1i;
W. ,, or that he is exemptnherefromand the basis for Be alleged exemption.Any violmionof
F Y
Section 7031.5 by any applicant for a permit subjects the.pplicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES i)
ce6 not more than five hundred dollars(55 W). V
❑ Lasownerorthepropeny,ormyemployees with wagesastheirsolecompensation, NEWRESIDENTIAL $Q.FTS P - r— �STORI TYPECONSTRUCTION
y will ratio,work,and Be antatureismainandedmoffemd forsale(SecJ044,Business I II\tl�
and Professions Code:The Convector's License Law does not apply to an owner of 0
property who builds orimproves thereon,and wh.dnes such workldmselforduough his
ownemployees.providedthetsuchimprovementsarenolintendedoroffemdforsale.If, .CR P RES.UNITS
however,the building or improvement is sold within one yearof completion,the owner-
-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,asownerofthepropery;amexclusivelycontractingwiBlicemedcontractors,. QTY. PLUMBI PER DOD NE ARN
construct the project(Sec.7044,Business and Professions C.de:)Tlie Contractor's
License Lawdoes not apply se an ownerofproparty who builds orimproves thereon,and PERMIT ISSUANCE
whomn[ractsfmrsaeh projects wlthac.mraetor(s)licensed Pimiento to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
[I1 am exempt under Sec. ,B&P C for this reason OUTBID FEES
BACK FLOW PROTECT.DEVICE
Owner Data SANITARY YN_
WORKMAN COMPENSATION DECLARATION DRAWS-FLOOR,STRIP,AREA,COND. RECEIPT'#
❑ Ihercby affirm,bat l have a certificate of consent to self-insure,macenificare of SCHOOL TAX Y N_
Workers Compensation Insurance or a cenified copy thercof(Sec.3900,Lab C.)which FIXTURES-PER TRAP - PARK FEE YECEIPr# N
overs all employee's under this permit RECEIPT#
Policy# GAS-EA.SYSTEM.]INC.4 OUTLETS
Company BUILDING DIVISION FEES 11 Certified .SYSTEM-OVER 4(EA)CertifiediCertified copy is hereby famished. GAS- PLANCHECK FEE
❑ cenified copy is filed with the city inspation division. GREASEANDUSTEL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE Of EXEMPTION FROM WORKERS' , GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This stelion need not be completed ifthe panni[is furore huad dollms($Mm SEWER-SANITARY-STORM EA.200FT.
or less.) ENERGY FEE
I certify that in Ne Perrormance.f the work for which this panni[is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person to any manner so as to become subject to the Workers' PAID
z Compensation Laws of Califomia. Dale WATER SYSTEM/TREATING
Applicant
Date Receipt#
I
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
F 4 become subject to Worker's Com smion TOTAL:
pen Provisions shall be a Labor evoked.0 must
a � forthwith comply with such Provisions or this permit shall h deemed revoked BUILDING FEE
LrJ A CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that dome is a construction lending agency for the performance of -
V O Be work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lka ti Lenders Name
O U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING HE
LklI certify Bar I have read this application and state that the above information is
a correct.I agree an comply with all city and county ordinances and stem laws relating to PERMITISSUANCE MP.CHANICAL FEE
building....Interim,and hemby.mhodze repmsensubcs of this city,enter upon Be
U z above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and 1,�0 �ttless to By of Cupertino against
liabilities.,JQg ts,custsanhichn yir way accrueagairet said City AIR HANDLING UNIT T`0 10,000 CFM)
Inversot lFce �fthe a two 1�peon
AIR HANDLING UNIT(OVER 10,000 CFM)
S of Applccttor Date EXHAUST HOOD(W/DUCO
PAID
If HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOg000 BTU) Date Receipt#
Will .applicant or fmure building occupant store or handle hazardous metedel
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25532(.)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will[he acomannimmut 89 building by
equipment which PAID BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hanrdous air contaminants es defined by the Bey Arco Air Quality Management BOILER- P M
Disvi.t7 COMP(OVP,R IW,000 BTU) 0
❑Yes ❑No
- NEW RESIDENTIAL MECH. SQ.FT.
1 have read the harardons materials ivilaremems under Chapter 6.95 of the ��� g 199
California Health&Safety Code,Sections 2550 !y3 5534. I understand Bat
oM#4?
he buildin snot cu dy-hamxla thet'tr yreso "ty to notify the
, Pan, t fury ems which be o issuance of a Certificate of ClTy Ur Uumn 1 INW
O an y. I�� � �
rte a odze ge am TOTAL: ISSUED BY�
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