25761APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBim' '- "-
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING. PRIIJ r IDl?SI'Ih'ICATION
PERMITNO.
25761 G 7 C q
J 1 U1
BUILDING ADDRESS:
A y1��'� ///���a��, '[r^
OVOID 1 l♦1( • Yom— N- UNIT# LOT#
SANITARY NO.
APPLICATION SUBMITTAL DATE
1 �`T�-�
OWNERSN PHON@
AWLIRCHIJNIC
`
COM CTO R'S NA LIC NO:
❑
CONTROL R
ARCHITE /ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG FlECT PLUMB MECH
PERMIT ISSUANCE
ICY ❑
01"'ALICENSED
CONTRACTOR'S DECLARATION
I hcrcbyuffinn That Inco licensed andcrprovlslnnmf Chapinr9(commencingwiN
APPLIANCES - RESIDENTIAL
LOB DG PITON
/\TlYprl=�J
Semon 70(m)of Nsiminn3ofihe Busimoottid Pofeaslon Code, and my license is in
PANELS
Yqe�
full force and effect.
License Class Lic.#
UPT0200AMPS 1
Date Contract
201 - 1000 AMPS
, S .FT. / R A ' $/SQ. FT.
I -• ^ M I
/ t`
"�
ARCHITECTS DECLARATION
1 undersund my plans shall be used as Public records.
OVER 1000 AMPS �. s ,
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC. `+✓
Licensed l'essional
OWNER -BUILDER DECLARATION
I hereby affirm That I not exempt from The Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: My city or county
`
TEMP. METER OR POLE NST. nATE
which requires n permiuo construct, altar, improve, demolish, or repair any structure
prior to its issuance• also requires the applicator for such permit to file a signed sutement
_
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractors License Law(@apter
9 (commencing with Section 70(u) of Division 3 of the Business and Proksniuns Code)
SWIMMING POOL ELECTRIC
VALUATjQE]^
or that he iseaempi loodnmanJ he basis fortheallegedexemption. Any violationof
Section 7031.3 by any apPlicam for ePermit subjects the epplicmnoeeivil penalty of
LTfS-SWITCHES-FIXTURES
'ban five hundred dollars (S500).
was of Ne property, or my employees with wagesas Heir sole compensation,
NEWRFSIDENTIALELECIR _SQ.FT.
STORIES
TYPE CONSTRUCTION
ill Jo tnewnrk, and the swcmm isnot intended oroffertJ foraile (Sec. ]014. Business
rid Professions Code: The Contractor's License Law does not apply to m owner of
property who Ani Ids or improves thereon, and who doessuch work himsel f or though his
ownemployces, providedthat such improvemenlsarenot intendedoroffered formic. If,
OCC. GROUP
RES, UNITS
however. the huildingor imprnvement is sold within one year of completion. Ne owner -
builder will have the burden of proving that be did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
sn1e")'
❑ I.asownerofthepropeny,enexclusivelycon=tingwiNlian¢dcontroctorsto
ccotormT the project (Sec. 7044, Business and Professions Cade:) The Contmetms
License Luwdocs not apply n'wownerofProperty whobuildn or improves Thurman, and
PERMIT ISSUANCE
wh,mnemcts ku,uchprojema witnacortowmrts) licensed pursuanno the Contractors
License Law.
AL 'fER- DRAIN&VENT - WATER (EA)
)
FEE SUMMARY
❑ 1 am carngx under Sec. , B & P C for Nis reason
BACK FLOW PROTECT. DEVICE
TMDF- FEES
SANITARY Y N
RECEIPT#
Owner Date
DMINS- FLOOR. ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ I hereby allirm that l have acenlfcma ofcoment mself-insure, oracenifeme of
Workers Compensation Insurance or a certified copy thereof (Sm. 3800, Lab C.) which
a
se's all employee's under, this permit.
SYSIF:My #
Policy
SCHOOL TAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK ITE. Y N
RECEIPT #
- - I INCA 0GTLETS
GAS GA.
BUILDING DIVISION MEN
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEE
❑ Certified copy is hereby furnished.
GREASEANDUSTRI, WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OP EXEMPTION FROM WORKERS
GREASEIRAP
SOILS IEI3
COMPENSATION INSURANCE
SEWER - SANITARY - STORM G. 2001T.
ENERGY FEE
(This section amid not be completed ifthe permit is foronchundred dollars(SHOT
orless.)
WATER HEATER W/VENT/ELECfR
I certify Net in the perfortnmee Of the work for which thisprnnitisissued.Isbell
not employ my person in any manner so m to become subject to the Workers'
Compensmionluwsof California. Dau
PAID
Date Receipt#
-
WATER SYSTF.MITREATING
Applicant
NOTICE TO APPLICANT: If. after making this Certificatenf Exemption you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to The Worker's Compensation provisions Of Ne Labor Code, you must
This pedt shill be demand revoked.
comply with such Provisions or No
BUILDING FEE "tforthwith
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm That here is a construction lending agency for the perf s munce of
the work for which this permit is issued (Set. 3097, Civ. CJ
TOTAL
ELECTRIC FEE:
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
Lender's Name
Lender's Address
I certify Thm 1 have read this application and arae that The out information is
coram'. Iagree tocnmply with all city and county ordinances and mute laws elating To
PERMIT ISSUANCE
MECHANICAL FEE
building construction , and by amhmiu repreae mons of Thiscityto enter upon Ne
above-mentioncJ pro npuryous.
ALTERORADDTOMECH.
CONSTRUCTION TAX
AIRHANDLINGUND('10 lo'cito CFM)
(We7 agree save. i emnify and hm a es, the CTry of Cupertino against
liabilities, judg ents, costs de mar,who, syinanyweyaccruea 'nstsaid City
AIR HANDLING UNIT OVER 70,000 CFM)
consequence +f The gmnT 8 f i�petmi
5
EXHAUST HOOD(W/DUCI)
PAID
ipmums.f Ap icmpCon a r e
If EATING UNIT (TO 100,000 BTU)
I IAZARDOUS MATERIALS DISCLOSURE
Date Reccipt#
BEATING UNIT (OVER 100,00l
TdI1PXL 9-11
Will thea 11 scant orfuere building Occupant moeorhandle houndous material
n defined ny the uperino Municipal Code. Chaplet 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RFSID)
Cade, Section 25 2(t)?
1:1 Ye ❑ No
ISSUANCE DATE
Will thea licamorfumre nuildin tusee tordeviecawhich emit
pp goy
4ea
BOILER- COMP(3HP OR 100.00) BTU)
the Air
hazardous air cmm�minams as ddineJ by The Bay Dau Air Quality Management
District?
BOILER - COMP (OVER 100,000 6'TU)
P410
TI
NEW RESIDENAL, MECH. SQ. FT.
❑Yes ❑Na
1 have read the ha odous tnmerials requirements under Chapter &95 of the
D
IVw
Califomiu Ilealth & Safety Code, Sections 25505, 25533 and 25534. 1 understand his,
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which most be met prior to issuance of a Certificate of
OccTm uy
o
ISSUED BY:
Owner or authoriexl agent Date
TOTAL:
OFFIGt