25349 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOECT'RTDA. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT -MECHAN
PLUMBING ICAL 2 5 3 4 9
BUILDING PROJECT IDENIFl�TH�-
BUILDINGAD RPSS: SANITARY NO. APPLICATIONSUBMI'ITALDATE
IINITM I.OTk
WN
E A Y P ONE: CONT �RS�AME: ULIC NO:
aNV NXCONTROL N
ARCHITECTIMOINEER: LIC N : ADD F ❑
a ztc�ram S5-
CONTACT: PHONE: QT'Yi" y3v -'ELECTRIC PERMIT . FEE Bl➢LDING PERMIT INFO
L4.,:nr.;'s`�iBLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-RESIDENTIAL
El
I hereby affirm rail sm licensed under fChater9 ommrncin JOB DESCRIPTION
VIOL, Y Provisionso p (c gwiN
ts1,O0f: Seninn]000)of Div"" Jof the Business tail siam Code,end mylicenx is in ppNE�
RR full force aril aZ SS 3 IIP,fO 200AMP5 -`..\i
Pa„ZW License Cl s LiC.q
m<L I Convenor 201-1000 AMPS
1'�yZ ARCHITECTS DE LARATION OVER IWO AMPS 5 Sq FT. EA .f/SQ.FT.
rZOrn^ I understand my plans shall be used as public retools, r j 'I 1 ��
y t W SIGNS ELECTRICAL
s LiPrnessiound
0.� anaW f
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. Lv� L'J ` Io IIS
%Oy I hereby affirm Not I em exempt from the Contractor's Licenx Law for she
u1 O to following reason,(Section 7031.5,Business and Professions Cade:Any city 0r county TEMP.METER OR MILE BAST. o
which requires a pemut to construct,ateq improve,demolish,or repair my swclore
Nprim to its ismance,also re dura he.pplicant for such permiuo file.signedstammrnt POWER DEVICES JI
G O that he is licensed pursuant to the provisions of the Commetm's License Law(Chapter
L o6' 9 with Section 7000 of ) SWIMMING POOL ELECTRIC � Y
(commencing wi ) Division lof the Business Profemiom Cade VALU///��A"��j"fffjjjYYjj�
_y mthat he is exempt therefrom and the basis for Ne alleged exemption.Any violation of / OUTLETS-SWITCHES-FIXTURES
E-Z❑a Section 7031.5 by my.,plicam frau permitmbjects the upplican[toecivilprndry of {7 w
r�G not more than five hundred dollars($500).G� NEW R65NFiNTIAL ELECRt -SQ.FT.❑ I,asownerofNepmWM.ormyemployceswithwagesmtheirsolecompenmfan, Q STORIES TYPECONSTRUCDON
y3. will dothewurk,and the swmme isnalin¢ndcdoroffeted formie(Sce.70,t4,Business
and Professions Code:The Comranar's License Lew deer not apply to an owner of
propertywhobuild.mimpmver therem.andwbodoessuchwork himxlfortluough Na
employces,provided that suchimprovementsaxnotimendW proffered foride.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
❑e)I,as rwnerofthe propeny,am exclusively cnnwcting wipe licrnem cmnemomto Q ,S," PLUMBING PERMIT FEE FLOOD ZONE APN
rostrum the project(Sec.7044,Business and Profusions Code:)The Commeno's PERMIT ISSUANCE
License Lawdoesnot apply toanowncrof rropeny whobuildsm improvesthexon,and
whowntmns fnsuch projects with.contractoohd licensed pumuant to the Conbector'n CA W
VENT License Law. (' ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this ocuum BACK FLOW PROTECT.DEVICE OUTSIDE
SANITARY Y N
Owner Date
DRAINS-FLOOR,ROOF, GOND.
RECEIPTp
WORKMANCOMPON DECLARATION SC3O0LTAX Y
N
❑ pmmNeef]C=Gfmo .cwof RECEIPfp
Workers'Compensation
o ionInsurmnceoraceiEed copy themof(Sm.390o,Lab C)which FIXTURES TRAP PABX FEE Y N
covers ell employees under this permit.
GAS-EA.SYSTEM-I INC,4 OUTLETS RECEIPT p
Policy g BUILDING DIVISION FEES
❑mCcnified copy ie hereby fomiehed. GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is film with Ne city inspection division. GREASFJWDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectimmad not becompletmRube pe.it is fortune hundred dollars(5100) SEWER-SANITARY-STORM EA.200Ff. ENERGY ME
or less.)
I certify that in the performance of Ne work for which this permit is ismer,Ishan WATER HEATER W/VENT/EIEM
not employ my person in any manner so as to becmrc subject to the Workers' PAID
Campenmtion awsof C.lifomia Data WATER SYSTEMITREATING Date - ReceiN0
Z Applicant
C)
C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOT
4 bccomith comply
fireesuchry Campmmtiisprrmitshall thelabor Code.you must BUILDING FEE
foMwiN comply wipe such provisions m this permit shill be dcemm revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC
z FEH
CJ I hereby affirm Nat Nex is a comm uction landing agency for the piceRma ince of
U O the work for which this Permit is issued(See.3097,Civ.C) TOTAL: ELECTRIC FEE
Lenders Name
D. Plenders Address - "MECHANICAL PERMIT FEE PLUMBING FEE
QTY:Ea"
L) 1 motif,that 1 have reed this epplicedon and state Net the above information a k h - MECHANICAL FEE
>" d coram I agree to comply with dl city and county ordinances and tate laws relating to MWITISSUXNCE
�-' building construction.and hereby auNmim representatives ofNts city to enter upon Ne CONSTRUCTION TAX
U 7 movcm dmonm property for inspecrim puryosd. ALTER OR ADD TO MECH.
G7 (We)agree to save,indemnify nd keep en the City of Cupertino against
liabilities,ju ts,cotamdex nanyway moeegdns,.dCity AIR HANDLING UNIT(TO 10,000 CFM)
in cc ofthe d
AIR HANDLING UNIT(OVER 10,000 CFM)
ignasure of Applican n x EXHAUST HOOD(W/DUCT) PAID
IIAZA OUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt a
Willtheapplicaut at..building occupant storeorhandlehmudou.mmedd
u deflated by the Ca mo Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I OOA00 BTU) TOTAL:
Code,Section 25532(h)?
13 Yee ❑No VENTILATION FAN(SINGLE.RFSID)
ISSUANCE DATE
Will Neapplicmmrfuturebuildingowupanl use equipmemordevicer whi<hemit BOILER-COMP(JHP OR 100,000 BTU) p
harardous A
air contaminants as defined by the Bay Area Air Quality Management BOILER. IOUM BTU) P D
•
District?
❑Yu ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have read the h.m ims mamd.ls requirements under Chapter 6.95 of the JUL 22 1993
California Hmth&Safety Code,Smanner 25505,25533 and 25534. 1 undersand Nm
if the building does not currently have.tenant.that it is my responsibility to notify the II I L1r
occupant of the requirements which must be met prior to issuance of a Certificate of SV V Uh'C IY
Occupancy.
Owner or amhmieed agent Date TOTAL: ISSUED B
OF I
v - ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION 'VALUATION
wNunEss/I��. i�lc�k/fn'.G X71 0 -
oxwERe _ _ -
��r '` FEE SUMMARY -
700—TRACTORs _ �j/. .'�"�/ KGs BUILDING
PIAN CHECK_ -
ADORE
SEISMIC
'f i C" FEE
SEISMIC FEE '
CITY. - ELECTRIC PERMIT' - . 'FEE' -
UTLETS-SWITCHES-RECEP - - " ELECTRIC
y LIGHTING FIXTURES 'c
PLUMBING _
APPLIANCES-RESIDENTIAL
_ PANELS
.MECHANICAL
SIGNS
SIGNS TRANS. TOT
SPECIAL CIRCUIT '
EMP.METER OR POLE INS- renm,T VALIDATIONMOTORS SEEFEESC_H.
S E$VICECHANGE_ _ _ '
zZ � ._ .� .r T -
F o TOTAL
ISSUANCE DATE
Cr > DTY. VLUMBINGPERMIT - FEE BLDG. c,vck vtc. MECH.
ao ❑ � ❑ ❑
- Z - ALTER-DRAIN&VENT-WATER(EA.)
- U 0 BACK FLOW PROTECT.DEVICELL
O,w, DRAINS-FLOOR,ROOF,AREq COND-
-} FIXTURES-PER TRAP -
F.Z GAS-EA.SYSTEM-I INC.4 OUTLETS'
0' GAS-EA.SYSTEM-OVER 4(EA.) -
INDUSTRIAL WASTE INTER. -
I- LAWN SPRINKLERS-1 INC 5 V.B:
LAWN SPRINKLERS-OVER 5(EA.) -SEWER-SANITARY-STORM EA.2001t/ ' -
WATER HEATER W/VENT.
'. WATER SYSTEM -
WATERTREATINGEQUIP. TOTAL
-
i.
- OTY. MECHANICAL PERMIT " FEE '
ALTER OR ADD TO MECH. -
APPLIANCE - - -'
4 4 AIR HANDLING UNIT 1T0 10pODCF.M)
AIR HANDLING UNIT(OVER 10A0CF.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.) {
HEATING UNIT(OVER 100.0008.T.U.) •••.������"`
VENTILATION FAN(SINGLE)
BOILER-COI4IP(3 H.P.or 100,000 B.T.U.)
' BOILER-COMP Iom'.IOD,DDDBruI SEE FEE BCH.
TOTAL