25152 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILD( .- LbC TR AL PERMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTTHEN'I'D'ICAI'ION 25152
BURDI ADDRESS: SANITARY NO. APPLICATIONSUBMIT"ALDATE
X
UNIT# LOT# C�y4�
OWNERSN ME: PHONE NTRACT R' P 1 NO: {•
• NIC CON TROL#
ITECT EER: LI NO: t1 E3O ACT: PN V!
QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFMInn�f,,
pyZ, (hereby vffir , licensed under provisions ol'Chapter 9(commencing with ,.I LOB DESCRIPTION
�z100 Semi on J000)a(Di ion of Ne Businessand Professi ndC y� y1,cc..,n PANELS G�y.a",
yQ Lican rte and elT /x 7
a..Z D Licen Lic# CJ UPT0200AMPS V`
VrQd me 0ntacwr 201-IOW AMPS
F' CTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
OZ- p rsmnd mY Pl a all sed as publi OVER 1000 AMPS
Qom ' tens ass el s SIGNSELECIRICAL
OWNER-BUILDER DF ARATION SPECIAL CIRCUIT/MISC. OV
��d'OyF 1 hereby affi that I am exempt from COnurseums License law for the
ty 3 tz-m
follow in8 reason action J03L5,Business an rofeasion oun
Cade:Any city or county TE METER OR POLE(NST. T, E IR
C w
E]�� which requires permit to consumer,alter,improve,demolish,or repair any snucture 4Z
>� psora its issuance,also requires the applicant for such Permit to file a signed statement FEWER DEVICES
Nm he is licensed pursuant m the provisions of the Contractor's License Law(Chapter
aaa4o�' 9(commmin
eg with Section 7")of Division 70f the Business and Profession Cade) SWIMMING POOL ELE C U
W_rn or met he is exempt therefrom and the basis for alleged exemption.Any violation of FIXTURES
OUTLETS-SWITCHES-
F-ZQ Section 7031.5 by mayapple.,for a permitsuhjecta the applicant too civil penvlry of �u
� p nor more than Live hundred dollars($SW). NEW RESIDENTIALELECIR _SQ.FT.
�m ❑ oche work,anheproperty,mmyemtendedwithwegeaasele(Sele c0mpenmion, STORIES TYPE CONSTRUCTION
a will Bothe wons C d e:no Contractor's License
Law red does non
apply t oan Business -
andpro Professions Code:The Contractor's License Law.ch not hinny to an owner of
is
ownenywhobuilmvidmproveuchimp,vemmu notint=dMowork r ffeoforue.his OCC.GROUP RES.UNITS
nemployecs,providedthmsu mentis vemrnain cafe iearoedmpletiod theowi.If,
builder r.wNeavet ebrdenof,movntissoldwithinoneyam or improve onJ purpose f TOTAL:
builder will have the burden o(proving Not he did not build or improve for purpose of
aleJ.
❑ I,as ownernFlhe property,am exclusively contracting with licensed convurorsto QTY. PLUMBING PERMIT FEE FLOOD LONE APN
construct the project(Sec.7044,Business and Professiorts Code:)The Comracmr's
License Lawdoesms apply manownerofpmpery whobuildsor improves thereon,end PERMITISSUANCE
who contracts forsuch projects with acontractor(s)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt undcr See. .B&P C for this reaaon SACK FLOW PROTECT.DEVICE O ID FEE
SANITARY YN
Owner Date RECEIPT#
• DRAINS-FLOOR.ROOF. COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX VN
❑Workers
Coyaffrtmthn Ilave. ofconsent Lab C.)which FIXTURES-PER TRAP RECEIPCp
Workers'Compensation&,thism rant.ficd copy there0f(SttJ8W,1abCJ which PARK FEE Y N
rs ell employ<c'a under this permit GAS-PA.SYSTEM-1 INC.4 OUTLETS RECEIPT*_
Policy p BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is Bled with the city inpection division. GREASRANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE.
(This sermon need not becompleted ifthe permit is(mote hundrddo11ars(SIW7 SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lcss.)
I cenify stet in the perfomomen of the work for whichihis permit is awned.I shall WATER HEATER WNEWIELECTR
.or employ any pe ram in any manner so as t0 become aubjem m he Workers PAID
Crmnenamion Laws Of Colifomia. Data WATER SYSTEMITRFATING Date Receipt#
Q Z Applicam
NOTICE TO APPLICANT.If.alter making this CerdBcme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FIE TOTAL:
Vi become subject a Ne Workers Compensation provisions ofthe Labor Code,you must
I-'-' forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE �#
LS.1
Q. Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
hem
on
V 7-. alk for hickaffironris .it is aconswec.301lending agency for the performance of
O the walk for which this permit is issued(Sec.301P,Civ.C.) TOTAL: ELECTRIC FEE
t-0 Lenders Name
QS^ Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
fJJ 1 certify that I have mad this application and sum that the above information is MECHANICAL FEF.
correct.l agree m comply with mi city and county ordinances and&late laws relating to PERMIT ISSUANCE
IA blildin,countlpeffoh,and hereby authorize rcprcseductNes ofthis city roamer upon the CONSTRUCTION TAX
L) z eWve-menti edp peny for inspation gores. ALTER OR ADD TO MECH.
(We) gran,m save,indemnify cep harmless rhe City of Cupertino against
liabiliri udgments,cosmandexpe whichmay in any way meraevgaordmid City AIR HANDLING UNIT(TO 10,0011 CFM)
I n ace of rhe grondngdt it.
AIR HANDLING UNIT(OVER 10,0110 CFM)
Know.of Applican , r Date ST HOOD(W/DUCp
PAID
f ARDOUS MATERIALS DI SURE HFATMG UNIT( .000BTU) Data Receipt#
Will theme Cau ine MrebuplC d,Camemreo,hundlehovrdh and Safety
I(EATING UNIT(OVER I W,00)BTU) I'OT
as defined hymn Cu Wino Municipal Code,Chapter 9.12,end the Hcahh and Safety
CwJc,Section2553 a)T VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE ITATE
Will theapplicantor futumbuildingacupant use equipmentardeviceswhichemit BOILER-COMP(3HPOR 100,0110 BTU)
hazmdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,001)BTU)
Distrim11? p�
Yes ❑No NEW RESIDENTIAL MECH. SQ,FT. P A y
I have read the hateadous materiels requirements under Chapter 6.95 of the
Colifomia Health&SafetyCade,Sections 25505.25533 end 25534. I undersand mat JUN 0 gy.1aa#Naa -
occu building does not currently have a mnam,that it is my responsibility ra notify the 3 ya`rR!/J�I
O
occupant of the rtqu'vemems which must be mm prior r1)issuance of o Certificate of
Occupancy.
Owner or authorized.gem Data TOTAL: