25427 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEPLUMBING-MECHANICAL PERMIT NO.
BUILDING DIVISION
N1oN APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS GN SANITARY NO. APPLICATION SUBMITTAL DATE
C -UNIT# LOT#
ERS N MU: V®n�� p ONE: CONTRACTOR'S NAME: ^ LIC NO: I,Tj N/C CONTROL#
63 � i
RC HITECT/ENGINEER: LIC NO: ADDRESS: ❑
TACT:
o L min u Raso .
NPHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
qq'�`�_� PERMIT ISSUANCE BLDG ELECT PLUMB MUCH
W � ❑ ❑
LICENSEDCONTRACI'OR'S DECLARATION gppIJANCPS-RESIDENTtnt
qyz, Thereby of
3 ofthnsedunss and
Professions
Cars,and
(commencing with �Jp$jyi ION
�s700 Secdon]Wd)of Dlvision3 of the Business end Pmfcseions Code,end mylieense is in ppryPLg
an V F full force and effect. ,
p,Z4 License Class Llc.# UPT0200AMPS
why Date Contmc[or 201-1000 AMPS
F y ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.IT.
Z O y OVER 10011 AMPS
O Z„F•, 1 understand my plans shell be used as public records. s
F H F��,yy
SIGNS ELECTRICAL
Lmensed Professional
Oil
OWNER-BUILDER mDECLARATION SPECIAL CIRCIJIT/MISC.
pg04T„ I hereby affirm that I am exempt from the Caucasians License Lew for the
1+134 m following reason.(Seaton]031.5,Business end professions Code:Any city or county TEMP.METER OR POLE MST.
coO
which requiresn permit reronswcL after.Tmcam forSucdemolish.orrepair artyswment
co<g prinr toslicensed pnamnt uires toth[he Prvisio.ofthe Comitte to fileasignednmemeat POWER DEVICES
p that he is licensed poreuant to the provisions of the Contracmta License Law(Chapter
4yorz 9(commencing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC
iC VALUATION
W_y nether h70315 enmpt apfmmand the basis for the alleged exemption, civilpledon of
Q Section]03 LS by any applicant for epetmit subjects the epplicen[wacivil penalty of OUTLETS-SWITCHES-PIXNRES
O not more then Bso hundred dollars($500).
Poi ❑ Lasownerofthepropeny,moryemployces with wagessestheirsolecomarromion, NEWRESIDENTIALELECTR _SQ.FT. STORIES - TYPE CONSTRUCTION
y will rotorw ak,and the structure ismaimended oroffered forsale(Sea 704 ,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorImproves[hereon,and who does such workhimselfieducughlik
con employees,providedthetsuchimprovementsareno[intended oroffered forage.if. OCC.GROUP RES.UNITS
however,the building ne improvement is sold within one year of completion,the owner.
milder will have the burden of proving ther he did nor build or improve for purpose of TOTAL:
sale.). TY. PLUMBING PERMIT
❑ 1,asownermftheproperty,amexclusively contracting with licensed contrattotsha Q FEE 'FLOOD ZONE APN
License the project(Sec.]M4,Business and Professions Code)The Convectors
License Law doesnm apply tomimenermTraperty whobuildsorimprovu daemon.and PERMIT ISSUANCE
who contracts forsuch projects with ammunitions)licensed pursumtlotheContmcmr's
License Law. ALTER.DRAIN&VENT-WATER(EA) FEE SUMMARY
+- .❑ I oro exempt under Sec. B&P C for this reason - BACK FLOW PROTECT.DEVICE OUTSIDE FEES
'SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS F, _ CO SCHOOL TAX YN
❑ Thereby affirm[heti have acertificate of consen[mself-insure,orettnificate of FIXTURE - ER TRAP I RECEIPT'#
Wnrker%Compensetion Insurance oracenifed copy thereof(Sec.3800,Lab C.)which PARK FEE Y_ry
covers all employee's under this permit. GAS EA INC�4 UTI.ET -------
]try p BUILDING DIVISION FEES
mpeny GAS-EA.SY R4(EA)
Certified copy is hereby punished.
¢LANCHECK FEU
❑ Certified copy is filed with the city inspection division. GR DUSTRL WASTE INTERCEPTOR— GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthapermit is formers hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or les'.)
I certify that in the performencemfthe work forwhich this Permit is issued,I ah all EATER WNENT/ELECTR
not employ any person in any manner so as m become subject to the Workers'. PAID
Z CAompsem anion Laws of Calif anis. Date WATERS M?BEATING Date Receipt p
Q O pp
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should IDENTIAL FLAIR. SQ.FT. TOTAL:
tO become subject to the Workers Compensation provisions of the Libor Code,you most
P4 . forthwith empty with such Provisions or this pemdt shall be deemed revoked. BUILDING PEE'
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
w Lenders Name
Lenders Address QTY. MEC14ANICAL PERMIT FEE PLUMBING FEE
0 V I certify that I have reed this application and state that the above information is
cavae[.lago-m comply with all city and county ordinances and state laws reliningha PERMIT ISSUANCE MECHANICAL FEE
building concoction,and hereby suthorire representativesofthis city to enter upon the
C) y above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
�7 (We)agree to save,indemnify and keep harmless the City of Cupertino against
liebilities,judgments,costs and expenseswiich may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
some re of a granting of this permit. .
AIR HANDLING MIT(OVER 10,000 CFM)
S' rata of Applicant/C itracmr ate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 BTU) Da¢ Receipt
Will the applicant or future building occupant share or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and rhe Health and Safety HEATING UNIT(OVER 1BLOW BTU) TOTAL:
Code,Section 25532(x)?
❑Yes 11 NO VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
B
3HP OR 100
COMP( , TU)
Will the applicant nrfuturebuilding oecme
upan[ase equipnmmut BOILER- '
hazadous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ:PT. p
I have read the hazardous materials requirements under Chapter fi 95 of the W
a iforam Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if the building does not curremly have a mount,that it is my responsibility to notify the /vJ�
occupant of the requirements which must he met prior lfi
to Issuance of a Ceneate mf (r� 0-11p.,Occupancy.
Owner or authonzed agent Date TOTAL: ISSUEDBY: 1
OFFICE