25713APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO- as,.CMUAL
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO,
25713
BUILDING ❑I]�� _ ` � NITN LIYfN
\\I�
SANITARYNO.
APPLICATIONSUBMfITALDATE
OW NA PHONE:
C NUsMy:
31V1�.
LIC NO:
N/C
❑
CONTROLN
ARCHITECI'/ENGINEER: LIC NO:
ADDRESS: s
1�
CONTACT: PHONE:
LE RIC PERMIT FEE
IQQ°"'*
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
❑ El ❑
LI CENSEDCONTRACTORRDECLARATION
undera mmecanse wish
Ih7")
APPLIANCES - RESIDENTIAL
pES
Ipp CRI
ofumthatl 3 ofthnsel
cid Proontions Code,an
for 7000) of Division J of the Business end Profeseionv Code, and my diose is in
ppNELS
�
Ia`^\','*•��Hyl as—
hot
hot
full farce and ct.
`�Tiy{Vtl,��
License Glaap— Lic.p -
UP TO 200 AMPS
Dale Contractor
201- 1000 AMPS
ARCHITECTS DECLARATION
1 undersmnJ my plans shall be used as public accords.
SQ. Ff. FLOOR AREA
$/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUE-DER DECLARATION
SPECIAL CIRCUITIMISC.
1 hereby affirm that I sum exempt from the Contractors Ucstue Law her the
TEMP. METER OR POLE MST.
following reason. (Section 7031.5, Business and Professions Code: Any city or County
which requires a permit m cooetruct, alter, improve, demolish, or upur any atructuu
prior to its issuance, alsorcquines the applicant for such pemtit to file aligned commons
POWER DEVICES
that he is licensed pursuant to the provisions of the Contracmrs License Law(Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)
or that he is exempttherefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by y applicant for a permit subjects the applicant to a civil penalty of
an
SWIMMING POOL ELECTRIC
VALUATION
66.�� ® p O p
I
OUTLETS - SWITCHES - FIXTURES
I'
not mom than fiofffieve hundred do][.
❑ Lvawne.andtproperty,ormyenpioyeeswithwegesmthe(Sec.
NEWRFSIDENTIALELECIR_SQ.FT.
S
TYPE CONSTRUCTION
7044. Business
will dathe wons and the ctureCon iumer's eal 7004. Business
and Code: The Contractor's License Law dove not apply m an owner of
he does notl apply
property whibu ndebo
ownertywhns, proored Ootsstheacoq Bndwtseranauchwork himselforthside.I.
acenm intendedmoffeacd beside.
employers,providedthatsuchimis
.G UP
RFS. UNITS
TO L:
r-
builder,the said it
avete burdenofamentisaat he diinot build of completion, theawntt-
builder will hove the burden of proving Nat be did twt build m improve for puryou of
ale.).
❑ has ownttof the properry,am exclusivelycontnctingwith licensed mntracmrs to
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
comtmn the project (Sec. 7044, Business and Professions Code:) The Co..'.
License Lawdoes not apply to an ownerofproperry whobuildn orimprovesthermn,aM
PERMITISSUgNCE
whocurntmcts fa®ch pr.*is with sommorclort0 licemedpursuant room Consracmrs
License Law.
ALTER -DRAIN&VENT - WATER (FAT
PEE SUMMARY
❑ 1 nm exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
O S D . .F.
SANITARY YN_
RECEIPT p
Owner Dnm
DRAINS -FLOORROOFAREAGOND
, , , .
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Thereby affirm that l have a certificate ofcomenfto self -insure, or a ceraficare of
WorkersCompensation lnsumareor acenifiedcopy themaf(See. 31300. LmCJ which
covers all employee's under this Permit.
Pol cy N
FIXTURES - PER TRAP
RECEIPT -
PARK FEE Y_N
RECEIPT N
GAS - HA. SYSTEM -I INC.4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certified ropy is hereby fomished.
GREASFSNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2WFT.
ENERGY FEE
(This section need am be completed ifthe permit is forone hundred dallars GPDE
or less.)
WAPATLR WN[NTtELECDt
I certify that a. On perforce of the work for which this permit is issued, Ishall
not employ any person in say manner so a to become subject in the Worker'
PAID
Compensation Laws of California. Date
ATERS TEM/IRFATING
Dote Receipt
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
RESIDENTIAL PLMB. SQ. FT.
TOTAL:
became subject ro the Workers Compensation provisime of the Labor Code, you must
forthwith comply with each provisions m thio permit shall be domed invoked.
BUILDING FEE
SEISMIC FEB
CONSTRUCTION LENDING AGENCY
I hereby affirm this them is a construction landing agency for the performance of
On work for which this pemut is issued (Sec. 3097, Civ. CJ
ELECTRIC FEE
Lenders Name
NameAddrem,
5'
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE ./�
Lender'.
1 certify that I have mad this application and sate that the above information is
Correct. l agree in comply with ell city amt county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby toothsome mpmscntutivua(thie city m enter upon the
above-mealioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSIRUC ION TAX
(We) agate to save, indemnify and cp humlus the City of Cupcnino agdnst
bilitiee,judgmenrs,c sH endc en May accrue-gv
AIR HANDLING UNIT (TO IO,OW CFM)
die
in onacyucnc of mai th' m, t.
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/)UCTT
PAID
Signet dl. Icractm Dam
HEATING UNIT(TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER H10,000 BTU)TO
Will the applicant or future building occupant sou or handle hezurdom mmerinl
as derided by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE MID)
Cale, Section 25532hd?
❑ Yes ❑ No
ISSUANCE. DATE
Willtheeppliemorfutumbuildingmcupantuseeluipmantordeviceswhichemit
BOILER- COMP(3HPOR 100,000 BTU)
BOILER - COMP(OVER 100,000 BTU)
hauNons air canmminenta as defined by the Boy Area Air Quality Management
Distinct?
NEW RESIDENTIAL MECH. SQ. FT.
❑ Yes ❑ No
P A I D
I have mad the hmardous materials requimmenm under Chepmr 6.95 of the
California Keith & Safety Cade, Sections 25505, 25533 and 25534. 1 understand that
if the building dues not currently have a mount, Nat it is my responsibility to notify the
Nov- 3199.
occupant of the re9uimmenta which most be met .or m issuance of n Certificate of
fxanpaacy.
IIYU f
ISSUED
Owner or uuthorizcd agent Date
TOTAL:
OFFICE