25329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO z"'."N x-ELLU MICAT PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25329
BUILDING ADDRESS, _ SANITARY NO. APPLICA'I ION SUBMUTAL DATE
NIT. LOT.
OW NONE: `� O C AME: O NIC a• CO[M�ROI�.p
RCIII'1'EC'DENGINEER: J NO: A ESS: ❑
ON'IAcT PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
DO ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESC N
OCP l hereby affirm chat l sin licensedmdm,nwisiunsofC-hapmr9(commencing with '
{Vu400 Scnion]fifth,nl Divis of Business P fcssion Cod• my license is in ,,HEIS
edw full forte and effete. n IIP TO AMPS / `
F Z WUW LicenseClass Lic.a Me,LLL (.
rir 6 Z �f Convector n 201-1000 AMPS
ZOv"sZ CHITECLS '/ OVER 1000 AMPS Q.IT.FLOOR AREA Q.IT
OZ'-O I under y plans shall be used us public rccods.
yFw SIGNS ELECTRICAL
�Q Y J Licensed Professional
04< OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
kOa V I hereby a0imr chin I am eaempl from the Canlm an's License Law for the
m 3 W ti following reason.(Section 7031.5,Business and Professions Code:Any city ar county TEMP.METER OR POLE INST.
L' 101 which rcquircs a maku,ism....cL alter,improve,demolish,m repair any maclurc
ad, prior its issuance,also requires the applicant forsuch permit file a signed statement POWER DEVICES
W K a0O that he is licensed pursuant to thehap
provisions of the Condommrs License Law(Cter SWIMMING POOL ELECTRIC
p•P,C1 9(commcncing with Seccion]IXKpof Division 3afthe Business and Professions Cade) VALUA N
W—N or lh.t he isexempt Racist. it Ne basis for the alleged!exemption.Any Achumnof
OUTLETS-SWITCHES-FIXTURES
F-Z¢ Secnot ore than by lvea undredicant ollars apermit subjects Mc epplicanno.civil penalty of
as
5=o not more than live hundred dollars($5W). NEW RESIDENTIALELECTR SQ,FT. Sq' RIES 'I'YPF,CONSTRUCTION
ad L0 1,asownerofchepmp ny,ormyemployeeswichwagesaaheirsolecomp oration,
oil 3O-2 will dothe woek,and Immucure is not imendedoroffeted forsale(Sec.]044.Business C^
and Professions Cade:The Contracwra License Law does not apply to an owner of
pro,mtywhabuilds mimprovesdamum,and wbodooseuch work hinoulfor through his ltdaa l/
nw
cmplaytts,pmvidedchatsuchimpmvementsamnmimendMoroffee forWe.If, I OCCGROUP RFS.UNITS
however,the buildingor improvement is sold within one yeurnfeampletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
'Vi1c')' QTY. PLUMBING PERMIT FEEFLOODZONIi AYN
❑ I,us owner ofche property,amexcluxivcly contracting with licensed contractors to
construct the project(Sm.7044.Business and Professions Code:)The Contractors
License Lawdecsnolapply man ownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
who mntrams fmmiliproject,with a c tracmr(s)licensedpurummt la he Contravenes
License Law. ALTER-GRAIN @ VENT-WATER(EA) IEE SUMMARY
❑ I am exempt under S«. B @ P C for This rtason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y N
Owner Date RECEIPTi!
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I hereby affirm that l have a cenifcam ofttmaen toself-insum,or a certificate of FI%TURES-PER'I'RAP RECEIPT.
Polhya Corel c upp�/pp�ttnifrMryythercof(Sm.38W,Lab C.)which PARK FEE BUILDINGECEIPONPEES
en ill mnpl y E'. 1 I/ -�y��///// GAS-G.SYSTEM-I INC.40I1TL.LTS RECEIPT N
Company 'fin/ GAS-EA.SYSTEM-OVER 4(EA) ^ LAR1CHf�6K.FFjT� n I
❑ Certified copy la edyum
❑ C'crtifed ropy is fled with the e city city inspeccinn division. GREASFJINDUSTRh WASTE INTF:RCF.PI'OR k GRADING Ir1iE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAPI) SOILS IEE
COMPENSATION INSURANCE, --
(This section need not be complccW if Ne pctroic is far one hundred dolhm(SIW) SEWER-SANITARY-STORMFA.2WFT. !
or less.)
certify that inthe pert ce of the work for which this pe pd lshnli WATER HEATER W/VENT/ELECTR
I I employ wy per res i Y mango as to beta❑ p is
ars PAID
Com tion a a )[ftiit
WATER SYSTEM/IREATING Dam Receipt#
Q z Ap[tlum
z2 NOTICETOAP IC 1'C If.aft makingthis Cenificam of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. O'fpL:
F" bmormsubjmuothd�Vlorkers na nmtiml previsions ofthe Labor Code,,ou must
� ,
forthwith comply wit uch prov.0 or this permit shall be Jmmed revoked. BUILDING PEE
�; CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
I hereby affirm that chem is a construction lending agency for the scrfomance of
U O the work fm which this Permit is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC PEE
LcnJde N.mc
W TY. MECHANICAL PERMIT FEE PLUMBING FEE
LcnJcr's Address Q
V 1 certify that 1 have read this application and state that me above information is
r�" W correct.I agree to empty with all city and county oninances and aux laws relating to PERMIT ISSUANCE MECIIANICAI.FEE
F' p" building construction,and hereby authorise representatives ofthis city m—acrupomhe
to CONSTRUCTION TAX
(� z abov(We)agree propcny for inspection pu ALTER OR ADD TO MECH.
I We)agree m sav ancmnify unWkh,,
loseless the City of Cupcnino ag.inst
Ilabilities,judgments, uandexpensemmywayaccnao,inm aid ly AIR HANDLING UNIT('10 10.0N)CFM)
in amscque f li t 's
AAAA jAIR HANDLING UNIT(OVER 10,000 CFM)
Signature. ,icmu1Comrazmr Ua EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS A' oecu DISCLOSardi
BEATING UNIT(10100,1%10 BTU) Dam Receipt#
Will the the Colmorfumesbuil goccupantport or handle hazardousmaterial
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety IIGTING UNIT(OVER 100,000 BTU) (ll'AI-:
Cad.,Sord..25532(.)! VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant Err future buildingmemant useeyuipment ordevices which emit BOILER-COMP(311P OR 100,1100 BTU)
he milwas air conmmiam s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) A
` District?
❑Yes ❑No NI?W RESIDEM'lAL MECII. SQ.IT Q1r�k e y
1 have mad the hazardous materials requirements under Chapter 6.95 of the L/Gy 1
Califnmia liealth @ Sufmy CMJ,Smcinns 25505,25533 and 25534. 1 undersand Net
ifthebuildingdoesnot currently have alene .that it is mymsponsibilitytonocifythe Ch Ur uur
capam of the requirements which must he met prior m issuance of a Certificate of --,/.I��g a
Occupancy. `+ �r 1
Owner or amhnrimJ.gent Dale TOTAL: ISSUED BY: