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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO�
BUILDING DIVISION APPLICATION/PERMIT
L raI A
PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
25818
dUILDIN D SS: \ �
xLOT#
SANITARY NO.
APPLICATION SUBMITTAL DATE �2 'yGll
/ l
OWNERS ME: PHONE:
/
'P„G /{!
C WT TRACTOR'S NAME: ICHO:
al. /� /
rr00
N/C
CONTROL#
CHITBCT/ENGINEPR: LIC NO: ADRRESS:
',s., rAve,,
CONTACT: PHONE:
QTY. ELECTRIC PERMIT
FET,
BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hembyaffirn Nes I am licensed underprovisionsof atipter9 (commede ngwith
APPLIANCES RESIDENTIAL
JOB DESCRI ON
l
Section ]000) of Division 3 of the Business ad Professions Code. ad my license is in ppryElS
full force and effe _!� UPT02MAMPS
License la� Llc.p
D Commctor �wLw�—V�—
201 - 1000 AMPS
ARCHITECT'S DECLARATION /
1 understand my glans shall be used as public records.
OVER 1000 AMPS
SQ. IT, FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I sm exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business end Professions Code: Any city or county
TEMP. METER OR POLE INST.
which requires a permit to construct alteq improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such pernitto file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9(commencing with Section 7")of Dlvlslo, 3 ofthe Business end Professions Cade)
SWIMMING POOL ELECTRIC
VALUATION
orthat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects te hepplicant to a civil penalty of
OUTLETS - SWITCHES - FIXTURES
S
not more than Five hundred dollars ($500).
❑ Lasowmemfshe preary,ormyemployeeswith wages astheirsoleconvemadon,
NEW RESIDENTIAL ELECTR SQ. FT.
IES
TYPECONSTRUCTION
wi ll do the work, and the structure is not in tended or offered for sale (Sec. 7004, Business
end Professions Code: The Connectors License Law does not apply to an owner of
own pmpeny who boiWs or improves thereon, end who docs such work himsdfor Nrough his
employees, pmvidedthwsuchimprovements arenotincended oroffered forsale. If.
OCC.G OU
RES. UNITS
however, thebuilding or improvement is sold within one yearofcompletion, theowmer-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
sale.).
❑ 1, as owner ofthe property, an exclusivelyconoactiag with licensed conmecmmto
QTY. PLUMBING PERMIT
FEE
FLOODZONE
APN
conanuct the projecs (Sec. 7044, Business and Professions Code) The Convector's
License Law does and apply to an owner ofproperty who builds or impmves rhereon,aad
PERMIT ISSUANCE
whecodracts forsuchprojects with a contractors) licensed pursuant to the Commetwes
License Low.
PETER - DRAIN&VENT - WATER (FA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & PC for this beeson
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT'#
Owner Date
DRAINS- FLOOR. ROOF, AREA, COND.
N
1 hereby affirm that I have a certificate of comsenrto sel6insure, ora certificate ofFIXTURES
orkes'Campensation Insurance or a caddied copy thereof(See. 3800. Lab C.) which
-PER TRAP
��
RECEIPT #
PARK FEE Y N
ars till employee's under this Permit.
Policy p
GAS - BA. SYSTEM -1 INC. 4 OUTLETS
RECEIPT #
BUILDING DIVISION FEES
_
Company
❑ Certified copy is hereby furnished.
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
GRADING FEE
❑ Certified copy is filed with the city inspection division. GREASFVINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OFEXEMPTION FROM WORKERS'
GREASE THAT
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be completed ifthe permit is for one hundreddollws(SIM) SEWER- SANITARY; STORM EA, 2MFT.
m leas.)
I certify that in the performance of the work for which this Permit is issued, l shall WAT IEATF.R W/VENT/ELECTR
note lay any peso - any man so eg n thew esufyeGiJo the Workers's17
PAID
C pensition Lry,a Valifomia. / _�.I
WATER SY TEM/TREATING
Da Receiptq
pPliean
NOTICE TO APPLICANT: If, after making tl' enificate of Exemption, you should
SIDENTIAL TIME. SQ. FT.
TOTAL:
become subject to the Worker's Carepensasion provisions of the Labor Cade, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
BU TNG E
S IC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructed lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOT
ELECTRIC F
Leaders Nunn
Lender: Address
QTY. MECHANICAL PERMIT
FEE
PLUMB( FEE
I certify that I have read ibis application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
PERMITISSUANCE
MECH (CAL FEE
building conswetion, and hereby euthoriurepresenmtives of this citymemerupon the
above-mentioned property for inspection purposes.
-
ALTER OR ADD TO MECH.
CON tRUCTION TAX
(We) some to save, indemnify and keep harmless the City of Contribute against
liabilities,judgmen6. costs and expenses which may in my way accrue against said City
AIR HANDLING UNIT (TO 10,0M CFM)
in wnsequemce of the granting of this pe it.
AIR HANDLING UNIT (OVER 10,000 CPM)
PAID
Signatureof Appllcent/Can anar Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT GO 100,000 BTU)
Date Receipt is
Will the applicant or future building occupant scare or hundle hazardous material
m defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
Code, Section 25532D)'t
13 Yes El No
VENTILATION FAN (SINGLE RESID)
ISSUA CE DATE
'
ccuntueq
Will she applicwtorfomrebuildingopa uuipmentordevices which emit
dom air contaminants as defined by the Bay Area Air Quality Management
(zarFY
strict?
BOILER-COMP(3HP OR 100,000 BTU) -
BOILER - COMP (OVER 100,000 BTU)
p�
r 11 sq
W 6N
❑ Yes 13 No
1 have read the hazardous materials requirements under Chapter, 6.95 of the
NEW RESIDENTIAL MECH.
-
/1 �]
��C 2
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not curently have a lead, that it is my responsibility to notify the
b
CIIy
Vi
receptor oldie requiremems which most he met prior to issuance of a Certificate of
Occupancy.
V i -L 1
ISSUEDB
Owner or amhorized egem Dem TOTAL:
OFFICE