25471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBING YUrRICA. PERMITNO.
APPLICATION/PERMIT MECHANICAL 1
BUILDING DIVISION BUILDING PROJECT[DEN"TIFICATION
BUILDINGA/DDDRESS: y/ SANIIARYNO. APPLICATION/SUUBMITTAL DATE
GPITf4 LOTH ONW�3
OWNERS PHONE: CO m NAME: LIC NO:
N/C CONTROL N
•ARCHITF,CI'/ENGINF,IIi: LIC NO: AD SS:7 D G4. ..,. ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDGEl PLUMB MECH
PERMIT ISSUANCE '��
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
p�Z I hcrebyaffilm that l utn licemedunder provisionsof Chapter9(commencingwith
00[— 0007 of Division J of the Business end Pra— ccnu is in PANELSce
C atm)• lam' f
¢Zw Licenxeandcff Lic.p UPTO200AMPS
lin Q ti Ddlt Conlfaelor.� / 201-I000 AMPS
Fa
ZOyZ s HITECI'S DECLARATION IVa OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.IT.
O Z-0 I understand my plans shall od used as public records. r^ ® B 1
lits(—u SIGNS ELECTRICAL pA..�.
QLicensedLicensedProProfessional='KOWNER-BUILDER DECLARATION SPECIAL CIRCU DMISC.
jeOaO 1 herchy.firm that I an exempt from the Commences License Law for the t
3 y fallowing reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
1.'u'O which requires a permit to<onswcl,aper,improve,demolish,of rcpeir any swclurc /
�wY2 prior m its issuance.also requires the applicant for such permit to file.signedamtement POWER DEVICES
m W G p that he is licmud pursuant to the provisions of the Communes License Law(Chapter
Y p,oK 9(almmendng with Section]O0()of Division 3 of IM1e Business and ProfessiosnCode) SWIMMMO POOL
ELECTRIC VALUATION
XX' ,, or that he is exempthcrtfrom and the basis for IM1e alleged exemption.An t f
,_,� g pion. ylPaioetu OUTLETS-SWITCHES-FIXTURES
FZa Section-/11JI.5by any se hundred
undre d.11..xapermit subjects the applicant civil penalty of
WSO n not than fiofihepndny,orniyempl NEWRESIDENTIALELECTR _SQ.FT. 5IORIES TYPE CONSTRUCTION
K F_o n❑ml.asowncrofthe property,nrmycmpinYees with wagesestheirsolecompensation.
W3°—° will do the work,and the structure is not intended m ufltred for sale(Sec. Business
:cod Professions Code:'ILe Commemr'a License Law does not apply to an owner of
property who builds or improves thereto,and whodoes such work himselfonhrough his
employ .provided that such improvements are not intended oroffered for sale.If, OCC.GROUP RES.UNITS
howees
ever.the building or improvement is sold within one years(completion,the owner- TOTAL:
builder will have the burden of proving that he did nut build or improve fur purpose of
We.).
❑ I,asuwnendlM1epmpery,ameadusivdycnnv..ling with licensed emorieofs to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.7044,Business and professions Code:)The Contractor's
License Lawdoes not apply to an ownerol'property who builds or improvestherma.and PERMIT ISSUANCE
whocontraas for such Projects with aasmracter(s)licensed pursuant to the Contractors ALTER (FA)
Limaxe law. FEE SUMMARY
❑ 1 on exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT
M
DRAINS-FLOOR.RUDE, COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I ❑ era'Co affirnlnInsurnce or cerci a copythersef(Sm.rc,or Lab C.))which
RECF.IPTN
Wmkels'Compcnsation Insurance or.certified copy thereof(Sa.1800.IsbCJ which FIXTURES PER TRAP PARK FEE YN
covers all employee's arthritis penal. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT M
Policy a BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenifid copy is Elcd with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMP IISATION INSURANCE
(This section need not be completed Here Permit is fortune hundred dollars($Hsi SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or less.)
I certify that in Ne performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECR
not employ any person in any m in,as to beconse subject to the Workers. PAID
Compenamianlawsof Califsmia. Data WATER SYSTEM/TREATING Dale Receipt is
O Z Applicant
Z Q NOTICE TO APPIACANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V] become subject to the Workers Compensation pmvisiom of the labor Code,you must
� ; forthwith comply with such provisions or this permit shallod md deemvokod. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z Ihurchy affirm meantime is a mnewmiot lending agency for the perfrmnanceof
U O the work far which this permit is issued(Sm.309],Civ.CJ TOTAL: ELECTRIC FFG
Lender's Name
U"' F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING 193E �•
0 V 1 cenify that 1 have read this application and state that the above information is
carat. l agree to comply with all city and county ordinances and state laws relatiogto PERMIT ISSUANCE I MECHANICAL FEE
I--' building conavoclinn,and M1creby nm@rriw rcprescnmlivez of this city to enter upon the CONSTRUCTION TAX
U Z above-mentioned ,Perry for lnxpcotion parlmees. ALTER OR ADD TO MECH.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
l ishilitoxjudgmers,costs and expenses which may in any way ccmeaguinst said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequences to gr.nti.g,,f this per",
2aAIR HANDLING UNIT(OVER IO,(XOCFM)
Signature of Appli omm`t Dam EXHAUST HOOD(WMUCT) PAID
US MATERIALS ISCLOSURF,
HAZARDOUS HEATING UNIT(TO 100,000 BTU) /- Data ReceiptM
Will the applicant or future building occupant store or handle haaaMous material HEATING UNIT(OVER IW,OOp BTU) T
as defined by Iend lse Cupertino Municipal Code,Chapter 9.12, the Health and Safety
Cd,,Section 25332(a)?
11 Yes ❑No VENTILATION FAN(SINGLE RESID)
Will the apPlicamturfmurt buildinguccupam uxequipmemordevices whichemit
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
. haturduus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A Y D
1 have read the hasmadous materials requimmenes under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand mal ��� O
if the building does not mrenlly have a meant,that it is my responsibility to notify the
«cupmt of me myuircmenm which must od mel prior to ixuanee tuf a Cenificem of
Occupancy.
Ownomminhorivedegem Data T ISSUEDBY1.'Y I �r NV