25744 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO EILBING-MECHA I PERMPf NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING CT IDENOFIC 25744
BUILDING PROIN,C1'IUF,N'1'IFICAq'ION
BUILDING ADDRESS: Lihdehbroo�r SANITARY NO. APTOCA'HON SUUaasB��.MITAL DATE
CS)(VX'' UNIT# LOT I l�lywyy
OW SNAMP.: rs� P0�5 CONTRACTOR'S NAME: LIC NO:
r!/1 N/C CONTROL#
ARCHITECTIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PCRMIT INFO
ry.QG ELO PLUMB MOH
PERMIT ISSUANCE I�C(t�
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RESIDENTIAL
p00 Ihereby afftmthat l ma 3.f,he licensed turovisiansofChCode,and
mmecense with
�ndo fullSection]OBO)efDivision 3mf the Businesv and Professions Code.and mylicense is in PANELS `
.<Zwfull force andeRxr.
6Zrrdd License Cazs Lic.p UP T02W AMPS
y Q a Dam Cmnraaor 201-IOW AMPS
7m ARCHITECTS DECLARATION OVER IOW AMPS SQ.IT.FLOOR AREA $/SQ.IT.
CZ-0
OO.z,- lunderslond my plurm shall be used as public records.
rm� F w SIGNS ELECTRICAL
Licensed Professional
LL OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Dia.W3I hereby am End I ana eumpt from the Cormourrs Licence Law for the
0following reason.(Section 7031.5,Business and Professions Cede:Any city or county TEMP.METER OR POLE INST.
which raqu,ms a permit to roosted dreg,improve,demolish,or repuir any slrucmre
E Y� prior to its issuance,also requires the applicant for such peanut or filessignedsmmmenl VI�Egs /5 f I^
p�C<p Ihethe is licensed pursuanno the provisions ofthe Contractors License Law(Chapinr
LL 9(mmmencingwilh 5xtian]OOB)of Division3ef the Business and Profeuiona Code) St IM NG POOL ELECTIi1C r � VALUA�f]N
a' � or that he is enem nhertfrom and the basis for the aIle ed sacro t An 1 t f clV
y p g pian. ylp aiono
FZa
Seeman 7031.5 by application fora laubjecssthe epplicemtoacivil O�TL S-SWITCHES-FI%]'URES
Y a^Y aPP parcel penalty of �G.—�
not mom Nan rive hundred dollen($5W).
O N WRESIDENTIALELECTR STORIES TYPE CONSTRUCDON
❑ I,usowncmfthe property,or my employees with wages as their sole compensation,
L3— willdo the work,and thesbunure isnotinwrded maffemd forsale(Sce.]044,Business
and Professions Code:The Centurions License Law does not apply w m owner of
propenywho buildsorimprovesthemon,andwhodam such workhmanalforthwugh his MC-GROUP RES.UNUS
however,
owprovided that such impmvcmc itsam notyearof doroffend(mule.If.
however,11 havodingor icom planning
thatsolhadidno,year olimpro efee heoes,r.of TOTAL:
builder will ham the burden of proving that he did no,build or improve for purpose of
ode). QTY. PLUMBING PERMIT FEE n.00D zorvE APN
❑ I, o e pecdc a(Sec.any,ama sin.,dyconvediions C licenseh eCorametno
Licenseconsumer the prosnot(Sec.]044,Business and Professions Code:)The Connacwrs
License Law Joesnot apply toenownerofprupery who builds or improves lherron,end PERMIT ISSUANCE
whocrnamenforsuch princess wiNa centimeters)licensed punuenttothe Conmemes ALTER-DRAIN&VENT-WATER E
License Law. ( A> FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE Y_B N
Owner Dale TIRECEIPTN
DRAINS-FLOOR,ROOF,ARCA,CONO.
WORKMAN COMPENSAONDECLARATION SCHOOL TAX YN
❑ en'Conaffirmihin I nInsureaora certnmfconxmrmcf(ee.380r Lab C.) whichm of FIXTURES-PER TRAP RECEIPI'p
Wmker%Compensetion Insurance orecertiriW copy thereof(See.38W.Lab C.)which PARK FEE YN
covers all employee's under this Permit. GAS-EA.SYSTEMA INC.4 OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EN) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASIVINDUS'I'RL WASTE INTERCEPTOR. GRADING FEL'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Dtismettonneedrol becomplemd iflhe permit is furore hundred dollms($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
roles'.)
I cenifylhat inlhe fumfonnenceofthe work for which this permit is issued,I shall WATER HEATER W/VENOELECR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensationlawsof California. Date WATER SYSTEM(IREATING Date Receipt#
Q z Applied.
Z 0 NOTICE 10APPLICANT:If.after making this Ccrditcale of Exemption,you should NEW RESI DENTIAL PLMIL SQ.FT. TOTAL:
becrnne subject to the Workers Compensation previsions of the labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
L2I Q CONSTRUCTION LENDING AGENCY SEISMIC FEE a
z 1 hereby affirm fail the.is a imuttionat lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
r- Leader'sName
OLeaders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 certify that I have mad this application and slow that the above information is MECHANICAL FEE
correct.I agree w comply with all city and county ordinances and Stam laws relating w PERMIT ISSUANCE
I— y
building mnstraim i,and hereby authorimmprcxnuliveaaflhiuiy locnlerupon the CONSTRUCTION TAX
(; z above-mentioned property for inspection pm
utpes. ALTER OR ADD TO MECH.
(We)agme m save,indemnify and lamp harmless the City of Cupertino against
liabdines,judgmems,cmas and espouses which may in any way accrue against mid City AIR HANDLING UNIT(TO 10j"CPM)
in co neence erg of thio pc
///9/9,3
� �j ny AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicea/Commosior O Date EXHAUST HOOD(W/UUC)
PAID
IIAZARDOGS MATERIALS DISCLOSURE HEATING UNIT(TO IW.000 BTU) Date Receipt#
Will the applicant or future building occupant swat or handle hamadom mateiW HEATING IINIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale.Section 25532(e)1
El Via El Na VENTILATION FAN(SINGLE REBID)
Will dicapplicam or future buiidiagercu BOILER-COMP UUP OR I bb,WO BTU) ISSUANCE DATE
pantux Area Air mdevicesem Lichemit q
Dburdous air contaminants ss defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER hal,OW BTU) #`a p
District] a'g '
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have mind the hawdous materials requirements under Chapter 6.95 of the
California Health&Safey Code,Sections 25505,25533 and 25534. i undersand that
if the building does not currently have a wrung but it is my mspmtsibility w notify Ne
occupant of the requirements which most be met prim to issuance of a Certificate of L(✓Nf SI
Occupancy. /Iii Y 1
Owner or vulhoriud agent Doe TOTAL: ISSUED BY:
OFFICE