25887 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .13 ' '-FI:ECTRrCA I. PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25887
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRFSg: SANI'PARY NO, APPLICATION SUBMITTAL DATE
��•f�\
2 V) tiI UNTI N LOT4 "Li-i's1-
OWNERS NAME: PHONE: CO RACfOR'S NAME: LIC NO: NIC CONTROL
.ARCI I ITF,C'DENGINEER: LIC NO: ADO IS: ❑
CONTACT: ONE: BUILDING PERMIT INFO
ELk QTY. ELECTRIC PERMIT FEE
BLDG EL PL IM
PERMIT ISSUANCE �
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
GCV Ihereby.M.dust 1nm IicenseAunderprovisions of Chapmr9(ectmnencingwilh
�00 Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
C�P. funm
force and effect.
QF Z W License Class Lic.N IIP TO 200 AMPS s
y6a Date Conttacmr 201-1000AMPS
p y I SQ.I.I.FI,ftOR n :n 5/SQ.r-f.
LSNZ ARCHITECT'S DECLARATION OVER 1000 AMPS LgORj
O>—G I undcrsmnd my Plans shell be used as pullet rxotds.
SIGNS ELECTRICAL
Q Licensed Professional
ww< OWNER-BUILDER DECLARATION L.SPECIAL CIRCUIT/MISC.
XOiU 1 he achy off that I an exempt from the Contranor's License Law far the
m 5 a y following reason.(Section 7031.5,Business end Pmfessions Calc Any citym county TEMP.METER OR POLE MST.
�
F0 Q which require%a permit to construct,alter,improve,demolish,or repair any structure
}� prior o its issuance,also requires the applicant for such pertain o file a signed statement POWER DEVICES
w KCp thin he is licensed pursumnmthe Provisions oldie Commerce License law(Clet'er
SWIMMING POOL ELECTRIC
D•LOLL 9(commencing with Section 7")of Division 3 offle Business and Professions Code) VALUATIIA
'ty��, or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �to � Os-{
H Z Q Section 7031.5 by any applicant far a permit suhjects the applicant m a civil penalty of L
5spnot stmt than five hundred dollars(5500). NEWRESIDENTIALELECIt SQ.FT. STORIIS TYPECONSTRUCITON
� � ❑ the
work,
andepropeny,ormycmpeeswithwegexamicisee.compensition,
y will dothesime,Cde:The Comstracture isnot intended,Licnse Law
formic(Sec to G4,Business
end Professions Cade:The Convector'.License Lew Jas not epPIY In an owner of
progeny whobuildsorimproves thcmmicadwhodesessuchwork him niforthrough his
OCC.GROUP RES.UNITS
employees,providedthur such improvema
enure not lntendelorofferd forsaLle.I
however,Inc building or improvement is sold within one yew afcompletion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
salt.). QTY. PLUMBING PERMIT FEE E1.00D ZONE nPN
❑ La%owneroftkpmpeny.amexclusivelycontmciingwithlicrnsedconuactOnm
construct the project Sec.7044,Business sad Freetown;Code:)The Contactor'.
Licrnse Low devanot apply loan ownerofpmpery who builds orimproves driven,and PF.RMI'1'ISSUANCE
who eantmets for such Pmjau with a convecbr(s)licensed pursuanno the Contrectoh
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em esempd under Sec. .B&P C fee this reason BACK FLOW PROTECT.DIiV ICE OUTSIDE FEES
SANITARY Y N
Owner Dare RAINS-FLOOR.ROOF,AREA.CON RECEIPI'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
• c❑ thereby affen Ran l have acenificatcofeemsentm self-insum.oracenificareof FIXTURES-PER TRAP .— RECEIPT
Workns Compcnssinn lmw
urceoracenifiedcopy thered(See.3800,Lab C.)which PARK FEE Y N
e
rs all employee',under Nis t. RECEI 'p
petrel GAS-EA.SYSTEM-1 INC.4 OU11 TI B TNG DIV lON
FUS
Policy N
Company GAS-FA.SYSTEM-OVER 4 BA) PLANCHECK '
❑ Cenifedcopyisherebyfumished.
❑ Cenified copy is filed with the city inspecuondivision. REASEIINDUSTRL WASTEINTERCEPPOR GRADING i
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP- / _ _ SOILS
COMPENSATION INSURANCE
(Thissection nesednotbecompleted ifthepnmidisforone hundred dmllms(SI W) SE - ANITARYt-1ST,(fy EA'2001Icr �_ ENER Il:
or less.)
I certify that in the performance ache work forwhich Nis pmmit is issued.I shall WAT6 HEATERW /ELE
set employ any person many manner so us ro become subject w the Workers' PAID
Compensation Lawsof Califomis. Dem WATFGAM12REATI Date ' t
Applicant
z NOTICE TO APPLICANT:If,after making this Cerifieme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. 'I'CTAL:
I-" y become subject to the Worker's Compensation previsions of the Labor Code,you must
foMveith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
0. (]
CONSTRUCTION LENDING AGENCY SE SMIC FEE D
Z I hereby affirm that there is u construction lending agency for the performance of
V O the work for which this Permit is issued(Sec.3097.Co.C.) O IiLECfRIC FEE
Leader's Name PLUMBING FEE
C'. F Lender's Address QTY. MECIIANICAL PERMIT FEF,
U 1 eerily that I have mad this application and state that the aMve information is MECHANICAL FEE
cared Iagree in comply with all city and county otdmenca and mate laws relating to PERMIT ISSUANCE
F" bulldingeonsaumion,and hereby iuthariu representatives miles city reenter upon the CONSTRUCTION TAX
V Z shove-norramed propcny for inspection purposes. ALTER OR ADD TO MECII.
1
'we
W c)agree emndy and keep harmless the City aI'Cupertino again t
liabilitiu,'u emu.cos dexpen hi ah may inanLwey=c=cegai dry AIR HANDLING UNIT(TO 111,00(1 CPM)
n cam nanung of this -
AIR HANDLING UNIT(OVER IR.CFM)
Signa ApplicaMContracmr Dat EXIIAUSTHOOD(W/DUC'I) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0t))BTU) Date Receipt#
Will the applicant or future building occupant store or handle varurdous material HEA'l'ING UNIT(OVER 100,0Xl BTU) TOTAL:
as defined by the Coleman Municipal Code.Chapter 9.12,and the Hedth and Safety
Code,Section 25532(a)t VENTILATION FAN(SINGLE RFSID)
❑Ycs ❑No
ISSUANCE DATE
Will thea applicant or fumrebmidin mxeui t ndevices which emit BOILER-COMP(3HP OR 80.000 BT'U) p
PP goccupen q Peen P A '
haaaNuus air conmminmu as defined by the Bay Area Air Quality Manegemem BOILC;R-COMP(OVER I00.01)BT117 �7
District? �{(j
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT. WAY O 9
I have read the havardous materials requirement.under Chapter 6.95 of the 1994
California Iledth&Safely Code,Sections 25505.25533 and 25534. I underawnd tum
fy the a'
If the building Jces not curemly have a tenant,thin it ix my reslam.ihility to noti
ry of
a
cupant of the mluiremenu which must be met prior to issuance of a Certificate of
Occupancy.
Owner m uuih.,i.d agent Dam TOTAL: ISSUED BY.
OFFICE