25868 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ala LacuitsPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /N ^�a
BUILDING PROJECT IDENTIFICATION L VX I6J V8
BUILD ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
NxrIT# LOT# '
OWNE@SNAME PHONE
CONT A R'S NA E: LIC NO:,
4S 7� I� G r �NIC7T CONTROLpARC11ITECT/ENGINEER: x LIC NO: ADD SS: p21
CONTACT: V
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
e- ' /_ PERMIT ISSUANCE BL G ELECT PLUMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
G]c47. m7000aueby f a that Division
3 Of the
derstandeap rovisifesions Corer add(commencing with �� IOB RIFT
&i-, fall
]Oa0) ffDivision3of theBusiness and Professions Cale,and my license is in PANELS
C U full force and effec
F License Cls. Lic.R 'UP TO 200 AMPS `
Fly Date Contractor 201-ItN10AMP5
ZO`t ARCHITECTS DECLARATI
O Z I undentund my plans shall be used as public records. OVER IOW AMPS f Q fT ARE S/SQ.PI'.
��4y5SIGNS ELECTRICAL
Ca� Loeneed Profees.Onul
OWNER-BUILDER DECLARATION
O U SPECIAL CIRCUIT/MISC
F I hereby affirm that 1 am exempt from the Conmamra License Law for the '
w3�m which ngmeson.(&riun]o3L5,Business uel,imrProfessions Co de:Any city nhmetracounty TEMP.METER OR POLE[NST.
IS,�� which requires u permit m conswtt,¢her,improve,demolish,or repair any structure
s5an prior to its issuance,also requiresthe applicant(orauchpermiuo fileasigned smoment POWER DEVICES
08 that 6e is licensed pursuam m the provisions of the Contractors License Law(Chaptr
W yo 9(oommenoing with Smdon]OPq)of Dlvision7of the Business end Professions Cade) SWIMMING POOL ELECTRIC
W_rn Onhat he is exempt therefrom end the bvis for W¢aIle ed exam tion.An VALUATION
8 P yviolbaby of SWITCHES- aaa.....
Q Section]031.5 M1y any applicant for a permit subjects the applicant to a civil penalty of OUTLETS- FIXTURES I� L BO�
Ca not more than five hundred dollars($500). ' 7
es; ❑ hasownerofth<pmpeny,ormy employees withwagcsesrheireolecompensation, NEWRESIDENTIALELECTR __SQ. STORIES TYPE CONSTRUC TION
L will Bothe work,and thexwawrels not inmodedoroffemdforsnla(Sec.]044,Business
end Professions Code:The Convector's Littnse Law does not apply to en owner of
pmpeny who builds or improves thereon,and who does such work Nmselfonhdough his
employxs,pravidedthateu<h
tittle.If, UNITS
however,the building nrimprovemem is sold within oneyearofrompletion,theowner.
builder will have the huNen of proving that he did not build or improve for purpose of A ; V�
sale.). a I'�
❑ I,asownerofthepropeny,um exclusivelycontracting with licensed contractors m QTY. PLUMBING PERMIT FEE FLO 0 APN
construct the project(Sec.7044,Business and Professions Cale:)The Cabddr,rs 'I'E
License Law does not apply to anownerofpraped whobuildsorimproves thereon,and PERMIT ISSUANCE
who contracts for such projects with sconrrallono)licensed pursuant tothe Contractor's
License Law. ALTER-DRAIN&VENT-WATER HEA) FEE SUMMARY
❑ 1 em exempt under Sea ,B&PC for this reason
BACK FLOW PROTECT.DEVICE OUTSIDE FEE
Owner Date SANITARY Y__ry
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
❑ 1 herebyaffirm that l have acenificamofenalvitto self-insum,oracertifcateof SCHOOL TAX Y N
Wmkers'Compensalion Insurance ora certified copy thereof(See.3800,Lab C.)which FIXTURES-PER TRAP ' RECF.IPTp
covers all employee's under this Permit PARK FEE y N
Policy# GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CEIPI'#
Company BUILDING DIVISI FEES
❑ Cordiiedcopyisherebyfumished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is N<J with the citIs
yinspection division' GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS PEE
COMPENSATION INSURANCE
(This section neWnot be completed if the permit is foioae hundred dollars Ell old SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orhas.)
I certify that in the performance ofthe work for which this permit is imued,lshall WATER HEATER W/VENT/ELECTR
not employ any perso n any nner s s to ,EcorR Iect to the Workers PAID
z Compens vs f ahfom', a 7 WATER SYSTEMiTREATING Receipt#
O ApplicuntTSCA
NOTICE TO APPLICANT:I,after making this Certificate Sic
i t bur o Code.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
H become hwithc mpyt to the Workers Compensation ermitshall beeLaborevod, moat
forthwith comply with such provisions Or permit shall be deemed revoked. BUI E
yCONSTRUCTION LENDING AGENCY S MI E
Z) Z I hereby affirm that there Is a oonstruction]coding agency for the perforrommO of
J
the
eName
work which this permit is issued(See 3119],Civ.CJ AL: EC IC
Z) U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMB GFEE
W 1 certify that I have read this application and state that the above information is
y 6i correct Iagree 0 comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECH NICAL FEE r
rA building construction,and hereby outhodmrepresentativesofthis city to enter upomhe
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONg UCf10N TAX
F7 (We)agree to save,indemnify and keep hortnless the City of Cupertino against
liabilities,judgments,casts and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00b0 CFM)
in con enc ofthegr tingofthispennit.
n AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Appl'enVContmctor Q401 Dale EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS Ming cap DISCLOSURE HEATING UNIT(TO 100,0!1(1 Bill) Date Rec t#
Will the the Cupertino
ino Municipal
occupant erre or handle hazardous materiel
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T
Cade,Section 25532(x)]
C1 Yes 0 N VENTILATION FAN(SINGLE RFSID) .
Will tair contaminants
is are defined by the
nBay Area Air unlit Management
BOILER-COMP QHP OR 100,000 BTU) ISSUANC DATE
Chaknorkars s et, air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No A
NEW RESIDENTIAL MECH.-SQ.IT. '
I have read the bandannas materials requirements under Chapter 6.95 of the 0� a�
Culifomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that PtiF
Plldf /
if the building does not currently have a tenant that it is my responsibility tonotify the Iy /
Occupant of the requlromcnts which most be met pd..Issuance of a Certificate of Cl l f
Occupancy. /
Owner or authonzed agent Dote ' ISSUED BY:
OFFICE