25079 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEPLUMBING-MECHANICAL. PERMIT NO. 25079
BUILDING DIVISIONSION APPLICATION/PERMIT
BUILDING 1'NUdECT IDENTIFICATION
BUILDING
/ADDRESS //�I Q A T/_ ///1� �L/ ♦ SANITARY NO. APPLICATION SUHMDTAl,DATE
1 l ®✓ (.—w��C/�W V Y. 31a 31—TiNITIII!�. CI�/CK.O LOT# s % 2
OWNERS NAM ' ,, 1� I PHONE: CO Cf $Nr E: SOS LIC NO: N/C CIIONROL# v
RCtHT13C1'/ENGINEER: W a/'(/_ LIC NO: ADDRESS;49 ef///- ❑
ONTACf: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PGRMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTNL
ZWz I hereby affirmthal l am licenxedunderprovisiotnafChapter9(commencingwith LOB DESCRIPTION
¢]00 Section 700m)of Division 3 of the Business and Pmfee;'p Code,and my license is in PANELS
FabE fullzW Lic forcnse and e(fx
<Zpl Liccnu Class Czg 37'S 24/ UP TO 200 AMPSkk *4 1A III
lis j y Date Convector 201-IINd AMPS SQ.FT.FLOOR A S/SQ.hT.
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS
OZ-0 lundersmnd mY Plans shAladusedmpublic recoNa.
r4tW I SIGNS ELECIRLCAL
g , Licensed Professional
G OWNER-BUILD ER DECLARATION SPECIAL CIRCUR/MISC.
�xx'OaU I hereby affirm Not I am exempt from the Casions Cs License law for the
W30< following rtaun.(Section]031.5.Business and Profession Cade:Any city or county TEMP.METER OR POLE MST.
Oco; which requires a permit to consumer,alter,improve,demolish,or repair any ewerure
Y� pricrto ire issuance,alsortyuGes theeppticsntforsuch factories,file asignW statement POWER DEVICES
TRAO Net he is licensed pursuant to the provisions of the Contracures Lomas,law(Chapter
' 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
L oVALUATION
Mon or that he is exempt ther@om and the basis for the alleged exemption.Any violation of — Ge
,Z� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES'-FIXTURES \Wnot more Nn five hundred dollars(f500). NEW RESIDENTIAL ELEmC 1k _SQ.FT. C
❑ I,mownerofthepropeny.armyemployaswith wegeaastheirulecompeation, STORIES 'TYPE CONSTItUCf10N
y3— will do N<work.and Ncstruaurt ianotinundedoroffertdloraele(Sa.7000,Business
and Professions Cade:The Contractor s License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his OCC.GROUP RES.UNITS
own employees,provided that such improvemems me not intended or offered for We.IL
however,the buildingor improvement is sold within oneyesr of completion,the owner-
builder .will have the burden of that he did not build or Improve for f TOTAL:
graving p purwaeo
sa1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
eanemud the pmjat(Soo.]DLO,Business and
uCode)The Cors
Licensetawdocs not apply manownerofpmpeny,whobddaorimproves themonsoand PERMIT ISSUANCE
whocnnt fmrsmch projects with amntraztor(a)licevforma
rat pumunt to the Connector's
License Law.aw. ALTLR-ORAL I T dif FEE SUMMARY
❑ I um exempt under Scc, ,B R P C far this reason BACK FLOW P lE I OUTSIDE F
ANITARY YN_
Owner Datc DRAINS-FL F. RECEIPTp
WORKMAN COMPENSATION DECLARATION CHOOLTAX YN
❑ Thereby art=Net i have a cenifrcete ofeement to seif-ir¢me,or a cenNcam of RECEIPT#
T Workers'Compensetion Insurance or a certified copy themed(Sm. Lou C.)which 1w A
FlXTURES-PER TRAP PARK Y N_
covers ail employee's under this permit. GAS-EA.SYSTEM- RECEIPT#
Policy# BUILDING DIVISION FEES
CO1nP GAS-EA.SYSTEM-OVER EA
❑ nified copy is hemby famished. ( ) PLANCIIECK FEE
Ce nified copy is filed with the city inspection division. GREASEMIDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Ibis section need not ecompleted ifthe permit is for one hundred dollars(SI00) SEWER-SANITARY-STORM EA.20011', ENERGY LLE
or less.)
Icinify that in the performance of the work for which this permit is issued,i shall WATER HEATER W/VENT/ELECTR
am employ any Person in any mammy so mearbec yro�-bj#�twlre Indians, PAID
z Compenustionlawsof Califord0 One J e f T lrS WATER SYSTEWITIE TING pate Receipt
Applicant
Z NOTICE TO APPLICANT:If,a(ter making this Certificate of Exemption.You should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Workers Compensation provisions ofthe Labor Code,you must
forthwith comply with such provisions or this permit shell he doomed revoked. BUILDING ME (1 fJ
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm Net Nene is a construction leading agency for the performance of TOTAL: ELECTRIC FEE
the work for which Thu permit in issued(Sm.3097,Civ.C.)
W U Lender's Name PLUMBING FEE
O U Ixad1 Address QTY. MECIIANICAL PERMIT NEE
W c I certify Nut 1 have mud this application and emte that the above information is MECHANICAL.FEE
6s
correct. Iagree ctcomply withallcity and county ordinancesand atom laws rearinghe PERMIT ISSUANCE
building construction,and hereby audtion purposes.repreeentetivu oFNis city roenter upon Ne CONSTRUCTION TAX
L) z above-mentioned progeny far inspection ,herALTER OR ADD TO MECH.
(We)ogres nt save,indemnify and kap hatmless the City or Cupertino L
libilities,judgmenm,cmuand expenses which n nny way
acmeagdrt send City
AIR HANDLING UNIT(TO 10,000 CFM)
In I, nee aftheIfofdtispemnit AIR HANDLING UNIT(OVER 10,00)CFM)
rs: IfeY3
Signature ofA man ontmcor Dau EXHAUST HOOD(W/DUCr) PAID
HAZARDOUS MATERMIS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dau Receipt#
Will the applicam or future building canteens store or handle hvallova mnerial HEATING UNIT(OVER 100,000 BTU) TOTAL:
m defined by the Cupertino Municipel Cod,Chapter 9.12,and the Health and Safety
Code,Section 25532(¢)?
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
Will heePPlicamorfmute huldinBoccu ant esu uiPmentortleviBOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
ices which emit
P
p A I D
t hazardous air contaminants tea defined by the Bay AmP o Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dun d7
C3 Y. 0N NEW RESIDENTIAL MECH. SQ.FT, rtrL rsV .a ay �a♦0*2
I have read be hseadous materials reyuimments under Chapter 6.95 of the y -may MH t 1 E 94
CuliGrmia Health @Safety CIA,Sections 25505,0533 and 25530. 1 understand Net 51 t P(/
if the building does not currently have a mount,Ihm it is my responsibility to notify Ne 4 cilly Uh i,,Ur Itl Iva
occurrent of the requirtmenu which mmst be met prior to isxio nce of a Certificate of
OccmPoncy.
OwnerorouNorized an, - Data TOTAL: ISS.EDBY:-\\ Y/s✓�