25393 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO UILDINGEEECTRTCAI. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENT'IFICA'TION 25393.
BUILDING ADDRESS: ///_gyp SANITARY NO. AFPLICATIONSUBMTITALDATE
64� W✓Z� UNIT# LOT It 1
O NCRS N E: PH'NE: D CO TRA R'S NAME: LC14S>9�
NIC CONTROL#
PRCBITECTfiENGINMR: LIC NO: ADDRESS: is
CONTACT: PHONE: - JT?'++ J"
QTY. ELECTRIC PERMIT _ FEE BUILDING PERMIT INFO
1 rAll"6+ BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-RESIDENTIAL
❑C 2 I hereby ailuro that l a mlicensedunderpmvisionsofChapmr9(commmcingwith JOB DESCRIPTION
plOLD Section 7")of Division 3 of the Business and Professions Code,and my boom is in PANELS
ly,V[� full force and effect.
Q p`f License Clasx Lie.# UPTO200AMPS
rFrr60. Dole Convector 201-1000 AMPS
F , ARCHITECTS DECLARATION �p FT. AREA S/SQ.FT.
'oo, Iunderstandm I OVER 1000 AMPS I7 p q
OZ-0 my shill be used rccoNs. i� Ids/
r^ w SIGNS ELECTRICAL Lz'o—'Q ] License)Pm(essional. OWNER-BUILDE0.DECLARATTON SPECLU.CIRCUIT/MISC. ` I 1 hereby nffiw that 1 sun exempt from the Contractor'sCo License Lew for thewhich
following (Section"/031.5,Business end Professions Cade:Any city stcounty TEMP.METIER OR POLE BJST.which requires n permit to ideas the elq improve,dmolish,or mash any srructurt
N;!IYn poorwitsilcsedissuance,..also ,to the
theapplicantfmxchpemtinw rile Licatse La suummt POWER DEVICES
asG Q that he is licensed Panum,to the provisions of Ne Conwaots a ittnu Lew(Chapter
Wm 9t that
he is exempthheefromandthe Division 3oRheedexemptio Professions Code) gWIMMB4G POOL ELECTRIC VALUATION
or�m Sectioheisexbysm,refromandlhe basis ubjeasegedexmsentto Anyviolationof OUTLETS-SWITCHES-FIXTURES
F Q
Section7031.5Chad, by anY applicant fora pontis aubjecu the applicant w e civil penmtY of i
Knot more @an five hundred dollors yemp. NEW RESIDENTIAL ELECTIt S .PT. ST vv�
W 22 ❑ I,osowneronhepvicuXt,armyemonadedwithwagesulbeirao[emmpemafion, Q STORIES TYPE CONSTRUCTION
p, will dothewons ands: nro Comisnotimenense Law
saide notaSeo.7044,Busir s.
of
and Professions Cade:The Contractors nd who one uch not apply w rt owner of
own apropertmployeas,provided
wyeas,pdsarimpmvesch improve nism tin n oroff oforWhhis
ownev p,oebsilding rim suchiniiswimenuertnorintendedoroffendfoeowne.If,
OCG GROUP RES.UNITS
bowcveoill have
t the bur improvement is aold within oneyeu of completion,Ne owner- TOTAL:
builder will have[he burden of proving That he did not build or improve for poupox of
sale)' TY: PLUMBING PERMIT FEE ZONE "N❑ I,asowncrefthepmp ay,emexclusivelycmwningwiNliunalconwctorew Q
construct Ne projcet(Sec.7044,Business and Professions Code)The Conwcmr'e PERMIT ISSDANCE
License Law doexam apply loan ownerofpropory,who builds or improvestbermn,end S d
whomnwetsforsuchpmjecuwithacantmewr(s)Iicmx pmt itotMConwemr's
Licenx Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 um exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE. ID FEES
SANITARY Y N
Owner Doe RECEIPT#
AREA
ROOF, ,
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, GOND. SCHOOLTAX YN
Iherebyu nsmthat1have.c acmtee con thwxlf-insure,o.ace C.)whioT RECF.IPI'#
FIXTURES-PER TRAP
o ers'Cnmpcnsa1 do I, ce orecrnified capythermf(Sec.3800,lsb CJ which .PARK FEF. Y_N
n ail cm I cis under this permit. GAS-G.SYSTF.M-1 INC.4OU1'LEIS RDIVISI p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Cmi�py is ertby f
'fid Certified copy is Rled wiN N<city inspection division. GREASE/INIUSTRL WASTE INTERCEPTOR GRADING FEE
7� CERTIFICATE OF EXEMPTION FROM WORKERS' GREtSETRAP SOILS LLE
COMPENSATION INSURANCE
(This eadonneed hi Completed lffie pewit is Trion hundred dollars($100) SEWER.SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfowance ofthe work for which lids pcned,is issued,Isbell WATER HEATER W/VENT/ELECTR
out employ any person in any ntvtner so as he bmome subject to to Workers' PAID,
Compensation Laws of California. Date WATER SYSTEM/TREATING Dau Receipt#
z Applicant
O NOTICE TO APPLICANT:If.after making N6 Carifiute of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
QO becomesubject to me Work.'.Compensation provisions of the Labor Code,you must
a ^^ forthwith comply with such provisions or,hi.panni,shot[be deemed rtvaked. DO[MING FEE
Lit Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affiwunit them it isieend(Sec.3097,
nsagency for the performance of
U O the work for which this pewit is issued(Sec.3097,Civ.CJ TOTAL: S ELECTRIC FEE
Leader's Name '-^C
;.J. U Lender's Address MECHANICAL PERMIT' FEE
PLUMBING IEE
UJ I certify that I have read this application and show that do,.bove information is MECHANICAL FEE
0Uvent. I agree Wcomply with all cityand countyordiuuncamWsuulawsrelatingto PERMIT ISSUANCE
buildingcounwction,and hereby amhoriu mprexnutivesof Ihischy Wenner upon the
U z shove. CONSTRUCTION TAX
men,im d property far inspection purposes. ALTER OR ADD TO MECH.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
liabi[ities,judgmenu.cmu andexpenseswhichmay inany way accrue against said City AIR HANDLING UNIT(TO 10,(10)CFM)
n"iten«of the gond of is permit.
'c AIR HANDLING UNIT(OVER 10.1100 CFM)
Pa.--
Applicant/Contractor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Data Receipt It
Will the applicant or future building occupant store or handle hazandms mncrid HEATING UNIT(OVER 100,000 BTU) TOTAL:,2,
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cada Section 25532(e)1 VENTILATION FAN(SINGLE RISID) -
❑Yes ❑No I� �a�
BOILER-COMP(3HP OR 100.000 BTU) r SIYAN CE DATE
Wiltheapplicanlnr fu turebuildingoccupanmxeyuipmenmrdeviceswhichemit 0+ A D
nz.Me a air contaminants as defined by the Bay Am.Air Quality Management BOILER-COMP(OVER IOQ000 OTU)
D string
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. EC u 9 ��Ap
Lbuilding
read the hazmdnm materials meuhaments under Chapter 6.95 of the tTs+� W3
California Health Code,Sationa 25505.25533 and 25534.I undersand that VI Y Ur ��r�H�lry
g does not currently have a lament.that it is my responsibility to notify the
the r,,ournsents which must be met prior to issuance of a Certificate of
horize l agent Dene TOTAL: ISSUED BY: