25667 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - YERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENY'IFICA'TION 25667
/Y)
BUILD` / •
I�NNGADDREES�X SANITARY NO. APPLICATION SUBMITTAL DA'11
O • 14 V UNIT N LOT N
Ow spa
ER NAy� a PHONE: CONTRACFOR'S NAME: LIC NO: NICCONTROLN
/n/
ARCHITECT/ENGINEER:- LIC NO: ADDRESS: ❑
CONTACT: PHONE: Qom. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARA'IgON APPLIANCES-RESIDENTIAL
pyz, Iherehy affirm shat l am licensed under pmvisionsofChapter9(commencing with JOB DESCRIPTION
caw O Satan]000)ofect. on 3 of the Business and Professions Code,and my license is in ppNpyS
Ufull fortt and cBxl. t
,-7W License Class Lic.0 UPTO200AMP5
F,<'y Data Comment, 201-IOW AMPS
Z 0,z ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z I understand my plans,bull be used as public meads.
P r!'F' SIGNS ELECTRICAL
<Y ,,j Licensed podex mud
=W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OO�!U 1 hereby affirm that 1 am exempt from the Contractors License Law for the
aoo fallowingreason.(Sermon713IS,Business and Pmf,,sions Code:Any city or county TEMP.METER OR POLE(NST.
F' O5 which requires a permit to construct,altar,improve,demolish,or repair any structure
�WQE prior to its issuance,also requires the applicanlfor such permit to file a signed statement POWER DEVICES
IY K O pm that he is Iicenaed Pa...,1.the provisions of the Conaacmr's License Law(Chapter
dKOLL 9(commencing with Section70(sh)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
µlimy
radial he isexempnherefrom and lhebasis forthealleged exemption.Any violation of
�ZQ see, .1.5 by any applicant for a perapplicant permit subjects the applicanoacivil penalty of OUTLETS-SWITCHES-FIXTURES
nm a than'Eve hundred dollars(1500). VSO VV
C � I,axowneroflhe NEW RESIDENTIAL ELECR 5 .FT.
moo property,mmyemployasroff for
c(Sme compensation. Q STORMS TYPE.CONSTRUCTION
a 3— will Professions
and the nmctu paxdasr' tLi cense Law dos net apply t 0an Business
and artywhions Code:The Conlremon, nd wbo law does not apply lf an owner of
prop.nywhos.proofimprovcsth imp andwhodassuch work oroffeor throughhis
veneer,thecuildin ori improvement
at dentis sold
dedmpletired fordue owner. -----UCC GROUP RES.UNI'T'S
builder ,will
building or improvement is sold within one year ofimponv lif r the ower TOTAL:
builder will hove the burden of proving than he did not build or improve for purpose of
sale.). .
❑ Lasuwnerofthepenpeny,am exdusively<onvaningwithlicenud conmactorsm QTY' PLUMBING PERMIT FEE FLOODLONE
APN
constructthe projat(Sec.]nay Business and Professions Crimp The Contractor's
License Law does forsucapply maWithacrnmateny who
nsedpurslds improves tharron, PERMIT ISSUANCE.
wM10 amtmda for such pmjcds with a c.naad.r(a71 licensed pursuanu.the C^nVacror a
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Stu. .B&P C for this reason BACK FLOW PROTECT.DEVICE O TSIDE FS
SANITARY Y N
OWna Dam DRAINS�FLOOR�ROOF.AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherch,wZ that l have a ccnificate ofcommrl toself-im^m,^raceniPcate of FIXTURES PER TRAP, pp Tn� pp 0 RECF.IPI'N
Workers'Compensation Insurance.,a certified copy thereoE(Sa.3800.Lab C.)which II\fl r tl •� A ;E I Y N
even allcmploYa'x under thin peri'. GAS�EA.SYSTEM-II C.4 OURETS RECEIPI'N
PolicyN BUILDING DIVISION FEES
Company /
❑ Certified copy is hereby furnished. GAS-G.SYSTEM�O (EA7✓ IECK E E
❑ Certified copy,is filed with the city inspection division GR EASF7INWSTRL WAS 1 EPI'OR GRMNG FE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCEFEEeP
(Tttis satin mad!nor becumplcred ifthc per mit is Enron.hvndraddollars(SIW) SEWER SANITARY-STORM EA.200FT.
or less.) ENERGY FEE
I cenify that in the performance,mine weak for which this permit is issued,(shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as 10 become subject to the Workers PAID
z Compenatexp awsof California. Data WATER SYSTEM/IREATINGApplicant Dam Raciptp
zC) NOTICE TO APPLICANT If,at.,making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Frn become subjat to the Workers Carepenswon pmvisiarmof Ne labor Code,you must
forthwith comply with such provisions m this permit shall lx darned revoked.
�i �_ BUILDING FF.E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affir that is a convection lending agency for the perfortnana of
U O the work for which this perit is issuad(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
I<ndera Name
UUnder Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I reality that 1 have mail this application and slate that the above information's
fir^ 0. cormm,l agree to comply with all city and county eardinarsaxic l slat,laws relating to PERMITISSUANCE MECUANICALFEE
_ fA building summoned,and hereby authorize represenmdves ofthischy to enter upon the
U z above-memiencd property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(ftInde ify and kap harmless the City of Cupertino againstliabililata pens. h It mayinany way eccoueageinnsaid City AIR HANDLING UNIT(TO 10,OW CFM)
(this
AIR HANDLING UNIT(OVER 10.090 CPM)
Si roof App VContreclor EXHAUST HOOD(W/DUC I
PAID
IIAZ RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam ReceiptIt
Will the opplicam or future building occupant store.,handle hazmdeus marmot
asdefined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,.00 B'TU) TOTAL:
Code,Section 25532(a)1
❑Yea 0N VENTILATION FAN(SINGLE RFSID)
Will thea licamorfummbuildingacu ant use BOILER-COMP SHP OR 100,000WTOTAL
.15SUA'CE TE
pp p Am.
unlit Management
it p/ q
hazardous air comaminanm na defined by the Boy Area Air Quality Management BOILER-COMP(OVER 1(10.0(10 B0A
Dialridl
❑Yea EI No NEW RESIDENTIAL MECITOCT �� 19Q
I have read the hvadoua materials requimmems under Chapter 6.95 of the i 3
California Health&Safety Cale,Swims 25505,25533 and 25534. 1 Understand that G�IY
ifthe building drxa nor amaill,have a wows,thal it is my responsibility)^nmifythe V 1 VI' `ut-willfs
ccupunl of the ouproamen.d which must be mel prior n'issuance of a Cer ifiaae of
Occupancy.
l Owner or authorized agent Date ISSUED BY:
OFFIC