25721APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO �T
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROh:C1'IDENT'IF'ICATION
PERMITNO.
25721
BUIL INGADDR SS: 1j_�'1t� ,`qw� �!/'�\�
li
2 Sr`If ` xF3CI — • IUNITar LOT#
SANITARY NO,
APPLICATIONSUBMUTALDATF:
I`ass,
22rTUX O
CONTRACTOR'S NAME: LIC NO:
N/C
❑
CONTROL #/
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:y'�f,:..r�z�
QTYy RSk19Fm+h E E,CTRI�C P . - :
ERMIT FEE
BUILDING PERMIT INFO
BLDG PLUMB MECH
PERMIT ISSUANCE
C�-'r ❑
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
1
"'afull
1 hereby off ret that I em licensed under prov islons of Chapter 9 (commencing wi th
) eDivision3of Ne Business and Professions Code, and my license is in
Sectiorce
ppNElg
andr
�♦
License Class Lie.#
uP TQ Zoo AMPS
� �
DoteConuacmr
201 - HXX AMPS
ARCHITECTS DECLARATION
1 understand my plans shall he used m public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
I I�
SISQ. FT.
SIGNS ELECTRICAL
V
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Conmcmro law fou the
TEMP. METER OR POLE FIST.
following reason. (Section ]W Business and e: Any
Code: Any city county
construct, ve. demolish, structure,
which requires u permit cu consweL thea improve, demolish, or repah any tment
is Nevisiosocant for pemduoLirile ase s(aapw
POWER DEVICES
that hepror lissnsedpalso rmant to the the Co License Law (Chapter
La
that he is licensed pumumno the ofDi am of the Ce Business
9 (commencing with Section 700(d of DivisianJe(Ne Business end Professions Code)
SWIMMING POOL ELECTRIC
V�1A�LU
or that he is exempt therefrom and the basis for the allegW exemption. Any violates of
Section 7031.5 by any applicant for a permit subjau the applican[ m e civil Pendry of
OUTLETS - SWITCHES - FIXTURES
re than five hundred dollars (S500).
Lasowrt. ov property,mmyemployecs withwagumtheirmlerompewtion,
NEW RESIDENTIAL ELECIR S . PI.
—SQFr,
p '/,a\S Wp IFF ®
^j
'f�PyrCQgSTRICrION
IPM
will hework,mdtheswnumir not imm�ded oroffercd (oreele(Sec.]D14, Bueincss
I J\ fL
r� \TIS
and Professions Code: The Com acini s License Law does not apply to an owner of
pmp nywhobuildsorimproves hereon,mdwhodoesmchwmkhismelforthroughlds
ownemployees.provided Net suchimprevemcnlaarenot imm�dedmoffcrcd foreale. If,
-
C O
'.UNITS
however, Ne huildingorimprovement is sold within one yearofcompletion, theewner-AITP
builder will have the burden of proving that he did not build or reprove for purpose of
�Ca/
+ .. ..
QTS'.1 , PLUMBING PERMIT C
9.
sale.).
❑ I, ev ownaafthc Prepeny oars exduanety cemraaing wuh licenaea contrxm t
construct the project (Sec. ]B1q Business and whobinos Cocke) The Cenmcmts
Licensecotrawdoeanmspplymanowncrofproperty whosedfaarimprovee Nereoaand
AIN
R ISSUANCE
PERMRISSUANCE
who contracts fico inch#rejects with acontrmmr(e)licensedpursuanuothe Convactole
License Law.
nI
ALTER - DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ sn exempt under Sec. , B & P C for Nis reason
BACK FLOW PROTECT. DEVICE
YID
SANITARY Y N
RECEIPT#
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
ARATION
WORKMANCOMPEcamofcN
SCHOOLTAX Y N
ni to
❑ era Colhcmbperson Omlhrance or aceni econxmmof(Sm.39,m Lab C.)) alcofwhich
WorkerA Compemationlnsumnceoracertificdcopy thereof (Sec. 3800, Lab CJ which
polcry ell employec's under this permit.
icy p
RECEIPT#
FIXTURES - PER TRAP
PARK PEE Y N
RECEIPT#
GAS - EA. SYSTEM -1 INC.40UTLETS
BUILDING DIVISION FEES
Company
❑ Cenified copy ishemby fanoted.
GAS - EA. SYSTEM-OVER4(EA)
PLANCHECK FEE
GREASFgWDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CMlfed copy is filedi with the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2001T.
ENERGY FEE
(This section need notbecompleted ifthe permit is forom hundred dollars($IN)
or less.)
WATER HEATER WIVENTIELECTR
,
IGmify that in the pMormvtce of the work for which this I mtit is issued, I shall
not employ any person in my manner so m to become subject to Ne Workmd
PAID
WATER SYYTEMfME VDNG
Compensation laws of Calif and.. Dam
Date Receipt N
Applicant
NOTICE TO APPLICANT: IL afer nuking this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject o the Worker's Compensation Provisions of the Luther Code, you most
forthwith comply with such provisions or Nis permit shall he hernetl .,.km.
BUILDING FEE xx�
SEISMIC FER
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency, for the perfmmantt of
the work for which this permit is issued (Sec. 309], Civ. C.)
TOTAL:
ELECTRIC ME
- -. sS L ^sx: -
QTY "^" MECHANICAL PERMIT v� - - FEE
PLUMBING FEE
Lender's Name
Lender', Address
L certify that I have mad this appliotm and .,a that the above information is
correct. l agree to comply with all city and county ordinances and slam laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingeomuuction, and herebyaut rance representatives of this city memarupon the
abwemcntioned property for inspection purposes. -
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO ID.0WCFM)
(We) time to save, indemnify and keep harrnleys the City of Cupertino against
liabilitiex,judgmena,costsmd expenses 'h y'nany way accruelgaimuaid Ciry
AIR HANDLING UNIT(OVER 10.000 CFM)
in con ntt of the, ting I. I
EXHAUST HOOD(W/DUCD
PAID
aws of rte /Cmuacmr Da
F
HEATING UNIT (TO IN," BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
HEATING UNIT (OVER 1110.000 BTU)
TOTAL:
Will the applicant or future building occupantaore or haNle hauardoustmled d
ss defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SING LERFSID)
Code, Section 25532(e)]
El Yea CI No
ISSUANCE DATE
Will upplicanmrfuwre buildingnccupantuseequipmemortleviceewhichemit
BOILP.R - COMP (JHP OR IW,0011 BTU)
BOILER-COMP(OVER 100.000BTH
harardom air commandants as defined by she Bay Area Air Quality Management
isaict]
❑ Yes ❑ No
4 jD
NEW RESIDENTIAL MECH.—SQ. FT.
1 have read the haeandous materials requirements under Chapter 6.95 of the
0� as I
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that
QC
if the building docs not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be not poor to issuance of a Certificate of
Occupancy,
1✓p $ 3
ISSUEDBY. ,tea 'asi a a
ir
OwncrornuNorisedagcm Dom
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OFFICE
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