25683 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO MICAL PERMITNO.
PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25683
BUILDING ADDRESS: I + SANITARY NO. APPLICA'f10NSSUUBMI♦TT,ALDATE
I 'UNIT# LOT It a- .�'/ / lG Z10
OWNE MC: PHONE: CONTRA 'SN ME: LIC NO: b///
7 N/C CONTROL#
CI F.CT/EN N R: LIC :� ADDRESS: ElQ
CONTACT: pxoNe:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PL B MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTIO
M=Z Ihereby affirm that l nm licensed underprovisions of Chapter9(commencing with
trJ 0W0 Section c a d Of Division 3 of the Business and Professions Code,and my license is in PANELSfall I // _ _
Ltoosec Clued eff u. ,L.� UP TO 200 AMP$ 1/�]�i�'IIyJ'✓1
co Dme�Crnuecmr 1 r 201-PIKEAMPS
SDECLARATION
ZOy� ARCHITECT' OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.ET.
CZ-0 1 understand my pleas shell be used as public records.
P4 W SIGNS ELECTRICAL •/,��
6,j ["1j Licensed Professional F4X ! p L E ® I
LIyaQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC,
UK! I hereby affirm that I am exempt from the Convector's License Law for the
W tr-y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
so; which requires a permit to construct,alter improve,demolish,Or repair any structure /10
Y� prions its issuance,also requires the applicant for such permit m file a signed statement POWER DEVICES DATE
''VV 7 J
0 O that he is licensed pursuant t0 the provisions of the Com actor's License Law(Chapter
ay K 9(commencing with Section 0000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VAI UA
i,yo urthmhe isexempuherefromand thebasiefrnhealI,M exemption.Anyviolationof OUTLETS-SWITCHES-
4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of FIXTURES
not more than five hundred dollen($500.
❑ I.asownerofthepmp ny,ormyemployeeswithwagesaslheirsolecompensadNEW RESIDENTIAL ELECIR 8Q'FT.
on, STORIES TYPECONSTRUCTION
ywill do the work,and the strucancisnotintended conflicted forxoc(Sec.7)44,Business
.. and Professions Code The Cmunic m's License Law does not apply to ea owner of
property wh o bui Ids or improves theocratical who does such work himsel f or through Ns
ownemployces,provided that such improvememsme not intendedoroffered provide.If. OCC.GROUP RES.UNITS
howeveg the buildingorimprovemem is sold within one yearmsompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
Wit.).
❑ I,as ownerofthe propeny,am exclusively contracting wit licensed convacmrsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professicas Coda)The Contrmum'e
License Law does not apply in an owneralfrepenywho builds m improves thereon,and PERMIT ISSUANCE
who convects for such projects with a crmrdcmr(s)licensed pursuant to the Contractor's
License Law. ALTER (E
) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason BACK PLOW PROTECT.DEVICE OUTSLD 'EES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOTAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm that l have a certificate ofconsentto self-insure,or a certificate of FIXTURES-PER TRAP RECEIPTq
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all empe's under this permit. GAS-EA.SYSTEM-]INC.40UTLETS RECEIPT#
P 1 cy# BUILDING DIVISION PEES
oraNny GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby furnished,
enified copy is fled wit the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection medical becompletcul ifthe permit is for one hundraddollues($100 SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or ess.)
Icertify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to became subject to the Workers' PAID
Z Con,ensmmalawsrf California. Date WATER SYSTEM/TREATING Date Reccipl#
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FI'. TOTAL:
H V) becameaubywt to the Worker's Compensation provisions of the Labor Code,you mast _
�i forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
PQ �] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of O ELECTRIC FEE
O the work for which this permit is issued(Sec.3099,Civ.C.)
IY r. lenme
ders NaPLUMBING FEF.
0 U Lender's Address QTY. MECHANICAL PERMIT FEB
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
ybuilding construction,and hereby authorize representatives ofthis city to enterupaa the CONSTRUCTION TAX
U Z alawe-mentioned property far inspection purposes. ALTER OR ADD TO MECH.
(W)ngree to save 'ndearnlfy and keep harmless the City of Cupertino against
liabilii jud ale andexpen,eswhich.,inanyway.c,.eagMnst,aid Ciy AIR HANDLING UNIT,0'010,030 CFM)
in iu Equere of1i '[
AIR HANDLING UNIT(OVER 10,1100 CPM)
rgnam o ppbram/COmmetor l Date EXHAUST DOUG W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
W ill the applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileahh and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(x)?
Wi
❑Yee ❑NO VENTILATION PAN(SINGLE RP.SID)
ISSUANCE DATE
Will theapplicantorfutarebuilding occupant use equipmenmrdeviceswhich emit BOILER-COMP(3HPOR 100,030 BTU)
hazardous air contaminant as defined by the Bay Area Air Quality Management BOILER-COME(OVER I00/000 BTU)
District? ❑Yea CINo yppy#
� A Q
NEW RESIDENTIAL MECH. SQ.FT.
1 have rend the hazardous materials requirements under Chapter 6.95 of the OCTlifornia Health&Safety Coda,have
ate 25505,25533 it is and 25534. 1 to nwnd that 1pY7 Iy ��
if the ent o the requirements
cuescurrenly which m tenant,be met it is my responsibilityoaernficat the `
occupant of the requirements which must be met prior to iesoenco o[a Certificate of I1
3 7/19j
Occupancy, CII y ur (;{
Owner Or authorized agent Date TOTAL: ISSUED BY: /
OFFIOr-