25395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINOPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
25395
BUILDING PROJECT IDRN'FIF'ICAI'RIN
BUILQING�IA(�DDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
V�• / - UNIT# LOT
PHONE: CONTRACTORS NAME: LIC NO:
D NIC CONTROL#
. ARC ITECI'/ENGINEER: LIC NO: ADDRESS:
ElCONTACT: .PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLU B MECH
PERMIT ISSUANCE �' ❑ j El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
CKz I hereby affirm that tum licensed under provisions of Chapter 9 firmamental,with
O 0 Section]000)of Division 3 of the Business end Professions Cade,and my license is in PANELS
WV full force and f
y License Clax -` 6th,?D Lic.x 4175" OTOS SSS RW at
— F
6
y[—pv0.i Date—��! - Contractor r
z Orm'aaa ARCHITECTS DECLARATION OVER 1008 AMPS
I understand my plans shall be used u public records. A I�
Y SIGNS ELECTRICAL O Y i
a Licensed Profeselonal
Lam That
Ian UILDER DECLARATION SPECIAL CIRCUIT/MISC.
K00.F 1 hereby affirm thus 1 em exempt from the Contractor's License Law for the
W 3 f-m following reason.(Section]031.5,Boniness and Professions Code:Any city memory TEMP.METER OR POLE INST.
f'01
which requires a permit te construe[,one,,improve,demolish,or repair any structure ATE
to prior 0 its issuance also requires the applicant for such pumiuo file a signed statement POWER DEVICES
(L O p that he is licensed pursuant be the provisions of the Contractor's License Use(Chapter
0.p,of1 9(commencingwitlt Secaon]000)of Division3ofthe Businessead Profusions Cade) SWIMMING POOL ELECTRICVALUATI]N
iW_rn or that he is exempt dmrefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES S�6 O•�S�\
QSection 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of _
t more than five hundred dollars(5500). NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION
Y n❑ hasowneraFlheproperty,ormy employeeswithwages es Theirsolewm,anom m,
y
.2 willdo the work,andthestmcture is notintendedoroffered forsale(Sce.]D14,Business
and Professions Code:The Commuter's License Law does not apply to an owner of
property w ho bu i I ds m improves distortional who does such work Morsel f or through his
employees,providedmianch improvementsue notintendedoroffered forsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yevofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, r opngus s , cmtructors to
QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.]044,Business and ProfssionsCode:)The,
Contractor's - AA
' License Lawdoesnotapplymanownerofpropeny whnbuilds orimproves Hereon,end PERMITISSUANCE
whocentracts forsueh projects with acomractor(s)licensed pumuantothe Contractor's ALTER DRAIN PA
License Law. HAT FEE SUMMARY
❑ 1 am exempt under Sec. ,B&.P C for this reason, ID F
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date pRAWS-FLOOR,ROOF,AREA,COND. RECEIPT# '
• cave WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that I have a ora certi ie consent er of(Sec.JI o,a ab C.)which
RECEIPT#
FIXTURES-PER TRAP
orkers'Compensation Insurance ora certified copy thereof(Sec.3800,Lab CJ which PARK FEE Y N
covers all an I Wader Nis t. RECEIPT
Policy#
M
IKnn' GAS-EA.SYSTEM-1 INC.4OUTLETS BUILDING DIVISION FEES
COm
❑ CCertess ified copy is hereyfmishcd. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
u '
'R Certified copy is filed with the city inspection division. , GREASF✓INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not W eempleted ifthepermit is Torose hundred dolbrs(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
m less.) w♦��1
I certify that in the performance ofthe work for which Wspumit is issued,Ishall WATER HEATER WIVENT/ELECTR aTTy
not employ any person in any manner so as to become subject to Ne Workers PAID
Compensation Laws of California. Date WATER SYSTEMfMEATING Date Receipt If
z Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Hh become subject to the Warian''s Compensation provisions ofthe Labor Code,you must
HH� ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
IxI Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that There is a construction lending agency for the performance of
Ne work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: j ELECTRIC FEE
w Lender's Name PLUMBING FEE
O U Lender's Address QTY. MECHANICAL PERMIT PEE
W 1 certify that 1 have read this application and sate that the above intermittent is MECHANICAL PEE
a act.Ingres mcomply with all city end county ordinencu and arab laws relating to PERMIT ISSUANCE
las building construction,and hereby authorise representatives ofthis city toentermem the CONSTRUCTION TAX
V �yy above-mentionW property for inspection purposes. ALTER OR ADD TO MECH.
(Wee)agree to save,indemnify and keep humless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT 17010,000 CFM)
onsequence oft gr ting of Nis permit.
AIR HANDLING UNIT(OVER 10,080 CFM)
�Imlore of Aplica VCom m
cr - f Date EXHAUST HOOD(W/DUCID
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will The applicant or future building occupant stere or handle hazardous material TOTAL:
as defined by she Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)4 VENTILATION FAN(SINGLE REBID)
ElYcs ❑No
ISSUANCE DATE
Will theapplicansorfuturebuildingoccupant useequipmem ordevices whichemit BOILER-COMP QHP OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. PAID
y p ' O
I have read the hazudous materials requirements under Chapter 6.95 of The T N1
California Hgdoes Safety Code,tlyha ea lem5505,25533 ymapo34.1underswnd that - - 9 1993
ifthe buildingdoesnot
ments yhaveastm that itis myresponsibilityernotify the occupant of the requirements which must he met prior m issuance of a Certificate of DECV
lap
Occupancy.
Owner or autionsed agent Date TOTAL: ISSUEDNaQIIY l �u