25788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OECUPERTINOB .1 .-ELECTRICAI. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROPF,C25788
'1'IDENTIFICATION
BUILNO ADDS: SANITARY NO. APPLICATIONSUBMITTALDATE
D
UNIT LOT#
OWNA C O ' E: LIC NO:
NIC CONTROL If
ANC II'MCDENGINEFR: LIC NO: AD ISS: Isk
❑
CONTACT: PHONE:
QTY. IiLECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE. 1:1 ❑ �I
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFMIAL
I hereby ffirm that l an licensed underprM.Isonsof Chater9(commencin
p0Z ya i p gwith JOB DESCRIPTION
0.100 fall ones,an)of Division 3.f the Business enO Professions Code,and my license is in PANELS
C U full farce ImA effect.
QZaw License Class Lic.# UP T0214)AMPS
m=y Due Conimctnr • 201-10X0 AMPS SQ.Ell FLOOR AREA $/SQ.F'r.
ZOoV1e'K ARCIII'I'ECTS DECLARATION OVER100AMP5
OZf-- ❑ Iunderswnd toy Plans shell healed aspublie records.
< f❑❑..W SIGNS ELECTRICAL
y„'I Licensed Pmfes.,iunal
V11''4 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
CEU I hereby mmor shut I am exempt from the Ceremonies License Law for the
31y milnwingrcasom(Section 7031.5,Business and Professions Code:Anycityor county TEMP.METER OR POLE INST.
C)I which rvuimesapcmtittoconstruct,alter,improve,demolish,or minor any structure
to its issuance,also then licant fmsucM1 no file a signedstatement POWER DEVICES
prior quires pp pemd
,<2 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencin with Section Rg10)of Division 3 of the Business and Professions Cade) SWIMMING MOL EL
14p� (commencing r� VALUATION
IN
1,G
Section
ethm h7031.5 by any rmmn,f the basis for tsth,llleged eaemart n.t.. isil,aion of OIITLITS-SWITCFI =FlX'NRES
F Z G not o re than
by any applicant for$pemtit subjects rhes apPlicanno a civil penalty of (\
W20 not momo*n oftherohundred
ny,ormyempl50(l NEW RFSIDIIJTIAL F.L V STORIES TYPE.CONSTRUCTION
aCho ❑ Lu.,k,.d,cs.mc, mfirmmployed wiohwed fardicirwl,cam Busineon.ss
3= andwill Professions Cade:
The ommnc is Lice d,Law doesan,apply to an Basin of
end 0,vEinns Cale:9be Commnnfs license Law does not apply lf an owner is DAT V
property whoes,pro or improves thereon,vera who ares such work himself m NwugM1 his
own employee.,pmvided thatwch impmvemenuart notimendedoroffared forstJ<.If. - O '.GROUP RFS.UNITS
however,the building or improvement is wld within mayearofcompleaon,the owner. TOTAL:
builder will have the burden of proving that he did wt build or improve for purpose of
sale.).
❑ I.mownerof the NuNny,ameachiuvely. convecting with licensed contractors to QTY. PLUMBING PERMIT FEE 11005ZO E APN
answer he pwject(Sec.7094,Business and Professions Cade:)The Comtmctor'e
License Law dotes not apply loan ownerofpropeny whobuilds orimpmvesthereon,and FERMITISSUANCH
whocommcts for such projects with a contractions)licensed pursuant to rhe Contmemr's AMER License L. (EA) FEESUMMARY
-•- -❑"1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE .IU.FEES
SANITARY Y --N
-
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,CONO.
WORKMAN COMPENSATION DECLARATION SCIIOTILTA% YN
❑ Irs'Cor Nma ton Insurance mi certified
copytherof(Sesurt,0r LabCfi.ae ofwhich FI%TURES-PER TRAP RECEIPI'p
Wnrkera'Compensmion Insurance ora renified copy thereof(Sec. Lab CJ which PARK FEL' Y N
covers all employee's under this Permit. OAS-EA.SYSTEM-I INC.4 OUTLETS RECEI"#
Policy N BUILDING DIVISION FEES
ny GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby furnished.
Certified copy is filed vim the city inspccomi dinkier. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXrNMON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This secures al not beeompleted if Ole permit is fmoae hundred drilars($100) SEWER-SANITARY-STORM EA:200FT. ENERGY FT:E
or less.)
.l certifytha math,pefumance of the work for which this amtit is issued,Is hell WATER HEATER WNFNTA'.LECIR
not employ any perm in any menncr ao as to became subject to rhe Workers' PAID
Z Compensation Lutes of Culifomiu. DaWATER SYSTEM TREATING e Uam Receipt#
Applicant NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
O becom TOAPPLICANT:If,after Commeent this endear ofof Exemption,youshould
� > b,shwithomplyt 1.rhe such pro Compensation prrout snsrftheemed Cvoked. must
? fnnhwith comply with such pnrviaons or this pcmtit shell be deemed revoked. - BUILDING FEE
W M CONS'TRUCT'ION LENDING AGENCY SEISMIC FED:
z 1 hereby from the there is n construction lending agency for rhe performance of
the work Inn which this permit is issued(Sec.309],Civ.CJ 'TOTAL: ELECTRIC IEEE
�O�.st Lender's Name
P
u" Lender's Address - - QTY. MECIIANICAF-PERMIT PEE. PLUMBING FEE
0 LUkII certify that I have read this application and state that the above information is
correm. PP.RMITISSUANCEI MECHANICAL PEE
) building construction,andhcmhy amhorimmpresenutivesofthiscityooenteruWn Ne CONSTRUCioN TAX
U Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MSCI I.
(We)agree or save,indemnify and keep hamdes the City of Cupertino against
liabilities. a u.cosuuerl seswhic yin any ay accrueagaiast said City AIR HANDLING UNIT(TO 10,000 CFM)
ime e the gaming rf thi. AIR HANDLING UNIT(OVER 10,000CFTM
3
sig; f phcamUCommnor IDate MIIAUSTHOOD(W/DUCD
rem
HAZARDOUS MATERIALS DISCLOSURE
I BEATING UNIT(TO 100,040 BTU) Dam BreciytN
Will he vpplicam atfuture building occupant xoom m handle hovrdous maeriil BEATING UNIT OVER 100,009 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and end the Health Safely
Code,Section 25532(a)P VENTILATION FAN(SINGLE RESID)
❑Vu ❑No
Will theepplicmwrfuwrc mBOILER-COMP(311P OR 100,000 BTU) a1SSVANCE DATE builJingoccupant useequipmen
rdeviceswhich emit ^-
haaartleus air comormicau ss defined by the Bay Arte Air Quality Managel11en1- BOILER-COMP(OVER 100,00)BTU) `UD�i
District? 999 V 1
.` ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ^/
I have read the mcm dous materials requirements under Chapter 6.95 of the
California l lcuhh&Safety Code,Sections 255015,25533 and 25534, l undetmand that L
ifilm building does neteurently have u tenant,that it is my responsibility tu notify the a Ufhh''
mccupam of the requirements which rust he met Inner tu issuance of a Certificate of
Occupancy.
Owne,miall naedagcnt Dam 1,: ISSUED BY:
I r OFRC