25857 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERM[F NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL.
.HUILDING PROJECT IDEN'TIF'ICATION 25857
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMI]TALDATE
N LOTH
O NAMEPHONE: CATORSALIC NO:
L s r 3 NC CONTROLN
ARCHITE ENGINFER: LIC NO: r DD ESS: ` ❑
CONTACT: PHONE: PR i� ry tI "fi-NL -N1. N w
TiY. .Y { ELE TRICt,PERMIT*k , 'PEE >3' :. .�.'DUILDINO PERMITdNPO'`"
E LDG ELECT PLUMB MECH
\ e S PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Myz Ihereby offtrm that l amlicensed underpmvisionsofChapler9(commencing with JOB DESCRIPTION
F400 Section]0011)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
FQ•uy LRill
canomrce fix elft Lic N 6 Z 3 UP TO 200 AMPS � �J 0`
to y Date Contractor 201.1000 AMPS
F y Z ARCHTIECI S DECLARATION SQ.IT.FLOOR AREA $/SQ.FT.
O Z^O 1 understand my Plw shall be used as public..MS. OVER 1000 AMPS
p rn t SIGNS ELECTRICAL
� p6$'; Licensed Pmfessionel
p�d OWNER-exempt RDEC Contra ON SPECIAL CIRCUIT/MISC.
O 1 hereby n.(Se that 1 w exempt from the Convector's License Law for the
3 O N following meson.(Seaton 7031.5,t,Business and improve,
demolish.
Code:Any city structure
TEMP.METER OR POLE INST.
J m which requires a permit re construes,eller,improve,demolish.t to fi repair any mortem
E 'hat
toslicensed pulwnttotsthehe visiosftherh Contacuse.License
Law(Chapter
POWER OEVICFS
Wp0a tha heienceng with Sction70(t)of provisions the Comrmmr.Licrnmlsw..Codi
d eLL 9(commencixemith Section RgldtheDivision3s.Heed.mnand Professions Code) SWIMMING POOL ELECTRIC VALUATION
Sectio b7031.5 by my applicant
the Perisfmtheellegedexempti m Aivil Peaion of A 1 d'�
6 Section L5 by any npPlicem fornpermit subjmu the applicant roecivil penally of OUTLETS-SWITCHES-PIXTURES
K mnot more than five hundred dollars($SM), NEW RESIDENOALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ I,asawnerofthepmpeny,ormyemploymswithwagesulkirsolecom m.tion,
y will do the work,andthe svuaumisnol inendedoroffered forsale(Sm.]0f4,Busineas
and Professions Cole:The Convectors License Law does not apply to rn owner of
property whobuildsmimprovw Nerma,m]whodoessuch wok himselforthmugh his OCC.GROUP RES.ON]IS
own employees,provided that such improvements arc not i mended pr offered formic.If,
however,the building m improvement I..old within one,sa.fcomplethm,thenwner-
builder wil I have the burden of proving that he did not build or improve for purpose of TOTAL:
Sale.).
❑ I,ssownero(Ihe propenY.amexcluarvelyconlncfngwithlicenrsed emblem to QTfYti Q' .,. PLUMBING PPRMIT, Li .e FEE;� FLOOD ZONE APN
mnsvun the prosect aply]014, nerof,usiness and Pmfasiow Code)ove therse ,and PERMIT ISSUANCE
License Law does not upply to an owns of property who builds rs improves thereon,end
who commas for Such Projects with aconvmbr(e)Iicrneedpursuant to the Conuncmra ALTER A
License Law. ( ) .,'FEE+SUMMARY
E] I am exempt under Sec. ,B&PC builds rcman BACK FLOW PROTECT.DEVICE
Ower - Data ROOFI, S Y N
GRAINS-FLOOR , ^' RECEIPI'N
WORKMAN COMPENSATION DECLARATION — 9 % YN
❑ Ihertby llfmn tholhaveacenifium of conmmto sel0insurt,aracenifcae of FlXTURES-PER TRAP /-` \ 1 'I II Iy FEB RECEIPTN N
Worker.'Compemation Insurance me cenified copy thereof(Sec,38011.Lm C.)which 1 1
oven all emphwey uMertFia pypry. GAg-PA.SYSTF?M-11NC.4TLETS RL•CEIPfp
Policy p `OOi I '—{'s B ILDING DIVISION FEES
❑ Certified copy is hereby furnished. GAS-EA.SYSTEM-OVER4(f �{}-ECHECKF
Dna Cenifed copy is filed with She city inspection division. GREASFgNDUSTRL NIASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplated ifthe permit is forms hundred dollars($100) SEWER-SANITARY-S3'ORM EA.20017, ENERGY ME
ar less.)
locrifyrhal in the ofonwtc.of the wok for which this permit is issued,IsM]l WATER HEATER W/VENTIELECTR
not a ploy any Person in any mama so an to becamesubject in the Workers PAID
Compensation Isw.of Ca ifomia. Date WATER SYSTEM/IRPATING Data Receipt N
O Z Applicant
Z R NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
r+ V) become subject to the Worker's Comporatir.Provisions of the Labe Code,you must
�i forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
a Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ 1 hereby afftem that Vert is a construction lending agency fm the performance of
O the work for which this permit is issued(Sea.JIM,Civ,C.) TOTAL: ELECTRIC FHE
lenders Name pv -
Lku f"I Lenders Address QTY, MECFIANICAI PERM17" +" �XFPP Y PLUMBING PF.13
V 1 comfy that 1 have read this application and ekle that the above Information P t' x v w^ '" .p "rr+«tGGBAah
0. correct.l agree to comply with all city atm county ordinances and some laws relating PERMIT ISSUANCE MECHANICAL PEP.
UJ BuildingcomoMd.,and hembyauthoria repsemnlauvesofthiscity wentaupon the CONSTRUCTIONTAX
U 4 above-mentioned property for inspection purposes. ALTF.RORADDTOMECH.
(We)agree to Save,indemnify and keep haemes the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(1-0 10,0110 CFM)
in mueace of the gr ng this preset'. 9
L _�J� AIR HANDLING UNIT(OVER 10,000 CFh)
tgnature of pplicanl/Cmarector Doo / EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CFO I0i BTU) Doc Rec4DTE
Will thatt,licanl or far.building nompant.ere or handle harsrdous materia HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cole,Section 25532(a)P VENTILATION PAN(SINGLC RE$ID)
❑Yes ❑No
Will theapplicaitorfnumbuildingoccupenl use ui BOILER-CORP(3HP OR 100,0(10 BTU) ISSUANCE
eq pmentmdevices whichemit
boredom air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes ❑No NEW R17SIDENTIAL MI3CH. SQ,1T.
I have mud the hazardous materials requirements under Chapter 6.95 of the PAID
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my respm¢ibility to notify the
o AN 24 19
reps at of the ar,iremms ewhich m
ich at be ren prim to I...of a Certificate of
Occuponcy.
Owner m milhmised.gentData 9'OTAL: ISSUED BCI
' O FICE