25011 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO TRICAL PBRMITNO. //��
APPLICATION/PERMIT PLUMBING-MECHANICAL. 2 5 0 1 1
\ BUILDINGDIVISION BUILDING,PROJECT'IDE"FICAT)ON V L
BOLL.DINO ADDR[SE: SANITARY NO. APPLICATION SUBMITTAL DALE
UNIT is LOTJa
O FRS NAME: r PHONE CONTRACTOR'S NAME: LIC NO:Id
NIC CONTROLg
0"-- 3
JCHITECf/ENGINEER: LIC NO: ADDRESS: ❑
coNTACf: PHONE: BUILDING PERMIT INFO
QT.Y, dr ELECTRIC PERMIT FEE
' BLDG ELECT PLUMB ME.CH
PERMITISSUANCE El 1:1 a% n
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ppfy Iherehyaffifin that am licensed underprovisionsofChapter9(commendngwi),
IY00fecImp1 OOI of Division 3 ofihe Business and Profession Code,and my license is in pAryp,LS
lFy�V
z,� full fame and effect. '/ y
License Class Lic.g UPT02MAMPS R
y6d Data Contractor 201-1000AMPS ��'YYY YiGG✓
z Fro K, ARCHITECT'S DECLARATION OVER IIxXIAMPS SQ.FT.FLOOR AREA f/SQ.FI'.
CZ-0 I undcrs ead my Plans shell be used as public records.
6-"K LicensedProfessiunal SIGNS ELECTRICAL F I 4 ALE D IN .
g0Wu OWNER-Bempt from
SPECIAL CIRCUIT/MISC. ,,
'a4 a 1 hereby affirm that 1 um exempt from Ne Contractors e:Any
law for the �III�
413 a y (allowing dra ox x(Section consumer.
Business andProfessions
improve,
dsio li Code:Any airy stcounty TEMP.METER OR POLE INST.
to O; UTER
which require a permit to construct,d,eq improve,demolish,or repair any strvcum �
F.`aso Y� priorm its issuance,also requires the applicant for such person to file a signed summand FEWER DEVICES fir
pa Nrsu
at he is licensed former,to the provisions of the Conneaut License Lew(Chapter
J eK 9(mmmencing with Section 7")of Division 3 of Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
to .,that he is exempt[here ..and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-FIXTURES
Y
Section 7031.56an
yyapilicimforepeunit subujaNeapplicannitidsil perWty of �Jl
Gnot mme than five hundred dollars($500).
pro ❑ I,asownttofthepropeny.ormyemployeeswithweg<sas Neirulecompemation, NEW RESIDENTIAL ELECfR _SQ.Ff. STORIES TYPECONSTRUCDON
will Jothesioendthe oreisratinunded orofferedfodele(Sec.7044.Business
and Professions
bu Code:The
Conmedors License law does not apply to an awns of
promployo ,,dsotimpraneschim, vndwhodcessuchandedomurmilthroughhie OCC.GROUP EIIN
w�e however,
the
ebu building
ng or lhaimprovement
mps vemenpronementsam not erandedmpietho d fm mmarde,If.
/J bidder will
bromprovementishat he id a., yed.,improve
theowncr- TOTAL:
/ builder will have the burden ofproving that he did rad build., far puryou of
est`)' QTY. PLUMBING PERMIT FEE FLOODZONE
❑ I,as the Pria"(Se pe 7W, exclusivelyc formationtromflog with licensed Connotations
cauwm the project(Sec.]044,Business and ywhobians Code:)The Cemorrar's
License whoctil.awdoor not apply man with acofpmpertywhosed Fsmisa tothe Contra and PERMIT ISSUANCE Sv
whence La,.v forsuch projadswithaconaa,or(e)licerucd punuant,othe Contractors AL-IER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
1`❑rI nm exempt under Sec. .B&P C for Nis reason TS
BACK FLOW PROTECT.DEVICE SANITARY V N
Owner Date DRAINS-FLOORROOFAREA, RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
Ihe"affirmthat I have a mi ificareofronumt o self-insum.or a certificate of FIXTURES-PER TRAP RECEIPTir
, , , ,
kers'Comperwdion Insurance aracertiftrdeopy thereof(Ser.3800,Lab CJ which PARK FEE Y N
coven ell under Nis ennit GAS EA.SYSTEM-1 INC.4 OUTLETS RECEIPTM
Policy g BUILDING DIVISION Tg3FS
Company �� (ark GAS CA,SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cen n capy,s hem y umuhed.
�ifled copy is filed with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
1
CC•RTIFTCAM MO NSATIO I N FROM WORKERS' GREASETRAP 5011,5 FEE.
COMPENSATION completed
INSURANCE
(Thissation need not be complered if the pennies is fm one hundred dollars(f IAO) SEWER-SANITARY-STORM EA.200FT. ENERGY FEB
aIc J F
Iceoy that in Nepro my nceofthe work for which,subject is the Wisdoms'
WATER HEATER WNENT/ELF.CIR J•�
not employ any person in any rammer so d in become subject to the Woheu' PAID
Z Companad
eion laws of Ctlifomie. Data WATER SYSTEM/IREATING Date Raeiptk
Applicant
Z 4 barome TOAPPLICANT:IL afarmvkingn prook ousiddin should inn NEW RESIDENTIAL PLMB. SQ,Ff. TOTAL:
Pr > hechwithcjadmNt Workers Coons in this
pervisiauofN amosed Coensed. mus,
t' � forthwith comply with such provisions ar,hispmni,shell be domed revoked. BUILDING I•liE
a
(� CONSTRUCTION LENDING AGENCY SEISMICFEE
UZ I hereby affirm that them is a cmutractior lending agency for the performance of TOTAL: �s 3 ELECTRIC FEE
O the wark far which this permit Is issued(Sec.NAIL,Civ.C.)
Lander'.Name
PLUMBINGFEE
Lenclers Address QTY. -r - MECHANICAL PERMIT FEE
..SC�
V I certify that I have mad this application and store
re,had the move information is MECHANICAL FEE
I2-) counter. l agree to comply with all city and county torments and sure laws relating o PERMIT ISSUANCE
f-' �"' buildingcommucdon,and hereby authotite repoeunmtivesofthisciry,to situation the
VI CONSTRUCTION TAX
V 7 above-mentioned 1.save,
nes purposes. ALTER OR ADD TO MECH.
C7 (We)agrte m save,indemnify end keep may ma y City of Cupertino against
IiaMlities,judgmenu,msumading of tenuermit. rsuy inanywey eccrveagainstsaid City AIR HANDLING UNIT(TO IO,OW CFM)
eonuquence of the granting of this permit.
S / 1_73 AIR HANDLING UNIT(OVER 10,000 CFM)
gm,ure of Applation/Comncor (O Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,Dfq BTU) Dau Receipt#
Will the applicant or future building occupant more or handle hammers material HEATING UNIT(OVER I W.000 BTU) TOTAL a.Ca So
as defined by the Cupertino Municipal Cada,Chapter 9.12,and the Health and Safety
Colo.Section 25572(n)P
❑Yea El No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicentmfumrt huildingmeupen,uucquipnrcntordevicdwhich emit BOILER-COMP(3HP OR 100,000 BTU)
h tendonair mnuminanu as th fired by Ne Bey Area Air Quality Management, BOILER-COMP(OVER Lou."BTU) � � I D
District?'
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT.
1 he.read the havardous maurials rWuimmends under Chapter 6.95 of the JUN 17 1993
California ia HeaI &Safety Code,Sections 25505,25533 and 25534. 1 understand that
if[be building Jces not currently have a moan,,Nat it is my responsibility to ratify the
occupant of,he requirements which must be met prior to issuance of a Certificate of CI I-Y Ur U YC
Occupancy.
Owrmr or umhmix d.gem Data TOTAL: ISSUED BY: