25386 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDINU-LLEU DUCAL• PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25386 5 a� O Q
BUILDING DIVISION M'(- 'BUILDING PROJECT IDENTIFICATION Jvv
BUILDING ADDD�RESS:/,a//�I ////�,/ p SANITARY NO, APPIUCYGONSUBMITTALDATE
D L/ I' /�-ae L UNIT# LOT# lO r`
OW ?RS ME: n PHONE: CO CfOR'S NAME: LIC NO:
� C A+NA qr NIC CONTROL#
ARCIIITfCI'/ENGINEER: C LIC NO: ' pDpp ESS I F. 9V
oft) ❑
ONI'ACT: - PHONE: `QIT. ELECTRIC PERMIT FE13 BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E 0 A 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nfez I hereby affirmation l amlictntod underprovisionsofaVler9(commencingwilh
Y100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANS
tp-sLBB full force and effc / Lic.# �•1 75 UPT0200AMPS
I6u2, License Cl f b P
tIo-6 h Ates
Curd runm � � 201-10(10 AMPS
ZOF ARCHITECTS DECLARATION OVER I"AMPS - SQ.PT.MOOR AREA $/SQ.FT.
O Z 40 ,1 undeuund my plans shall be used ns puhlic records.
149Pw SIGNS[LECfRICAI.
Licensed Profession
P OWNER-BUILDER DECLARATIONCmduame SPECIAL CIRCUIT/MISC.
W "l- I hereby M.that 1 am exempt from fibs Con cesCo License Ww for the
W 3 o o, followingreason.a (Section 703 L5,Business and Professions Code:My city s county TEMP.METER OR POLE INST.
�-�� which requires n pcmds m construe,alter.improve,demolish,or repair any swcmm
7 lj inform its issuance,also requites the applicant fm such pewit w file a signed statement POWER DEVICES
�a�C3 O Rod he is licensed pursuant to Ne provisions of the Cwtractors License Law(Chapter
4 e 9(commend,with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Pm or he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
1-. Q Sec inn 7031.5 by wy applicant for n pewit aubjecu the epplicnnt[a a civil penalty of
not moreown rofhund rtollurmycml). NEWRFSIDENTIALPLECTR _SQ.FT. STORIES TYPE CONSTRUCT ION
0 ❑ I,nsownerofthepropeny.army cmployccawilh wagesas theiraolecompensmion,
L will dnthewor,and the shuctmdomm',Lidcdnro.doesrtmo(Sec.to ano owner
and Professions Code:The Cnmmcmrs License Law does not apply m an owner of
ownertywbees,promimpovesth impooedwhn doessuchwmkhimxlfenhroughhis OCC.GROUP RES.UNITS
awnemployees,providedthatsuchimprovementsarenos cennfo nofferedfmsale.IL
however,the building orimprovement is cold within m build o improve
theewner- TOTAL:
builder will have the burden of proving that he did non build m improve fm purpose of
seta.).
❑ Las ownerofthe property,amexclusivdycontracting with littmedconwervnm QTY. PLUMBING PERMIT FEE FLOOD ZONF. APN
construct the project(Sec.7044,Business and Professions Cedc:)The Contractor's
Licenselawdeesn.I apply tout ownerofproperfy wh.buildamimprovesthemon,and PERMITISSUANCR
who contrutt for such projects with a contractor(s)licensed pnnuam m the Conduct
License Lew. I AI ' E T WA R -,SUMMARY
❑ I am exempt under See. 8&P C 6r this mason t L FEES
AUIy L W R 'TI 'f.C Cb SANITARY Y—N-
0.., Dem D N -hOO O ,ARE C D. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that l have a certificate ofcenxntto self-foam,ora certificate of %TURFS-PP.R RECEIPT#
orkers'Compensation lesumnce ora certified copy thereof(Set.3800,Lab )which DQ PARK FEE V N
Covera ell der ads pewit. RECEIPT#
co,c.Policyp �, GAS-EA.SYSTEM-1 INC.40IITLETS BUILDINGDIVISIONON FEES
Company stal'Y' er`
❑ Cenifmd copy is Acraby funis ed. GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
Cenirtd copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe pewit is forma,hundred dollars($100) SEWER-SANITARY-STORM FFA.2WFT. ENERGY PEE
or less.)
I cenify,that in the Performance of the work for which this pewit is issued,l shall WATERHEATER W/VENT/FI.ECIR
not employ any person in any mane,an m to become subject to the Workers' PAID
Compenmtien I-awsof California. Date WATER SYSMMIMEA71NG Data Receipt#
C) Z Applicant
Z NOTICE TO APPLICANT:if.after making this Cenificam of Exemption.you should NEW RESIDENTIAL PI.MB. SQ,FT, TOTAL:
(•-' N Iteceme subjecuo are Webers Compensation provisions of the Labor Code,you must
7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMICFEE
V z 1 hereby affirm tharthem is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3(197,Civ.C.) TOTAL: ELECTRIC ME
O Lcnder'a Name "t,g"
0 (U+ Lcndcr'a Add., m0;Iry, `,$ ;y'*MECHANICAL PERMIT, "FEE PLUMBING FEE
1 cenify that I have ad this application and state that the above information is '!
0. conecl. I agree to comply with all city and county ordinances and somelaws relating to PERMIT ISSUANCE MECHANICAL.FEE
y building construction,and hereby amhorim representatives ofthis city faculty upon the CONSTRUCTION TAX
U Z above-mentioned property fm inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
Iiabilitanjudgmenu.costs endc.pcd a which may inanywayaccrueagsimt aid City AIR HANDLING UNIT(TO 10,000 CFM)
in conngerye of the grdrtm (Jha Permit. AIR HANDLING UNIT(OVER 10.1100 CFM)
/mel) rib
Signature of ApplicanUC actor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1W,Ik711 BTU) Date Receipt#
Will the applicant or future building occupant some or handle hazardous material HEATING UNIT(OVER 100,0(1(1 BTU) TOTAL:
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? VENTILATION PAN(SINGLE RFSID)
❑Yes ❑No
W0l the applicant arturvrebuildingoccupant useequipmrntordevicea whichemif
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Nous air conumimarts as defined by the Bay Men Au Quality Maneggme0l BOILER-COMP(OVER 100,000 BTU)
inrict? �D
❑Yea ❑No NEW RESIDENTIAL.MECH. SQ.FT. A I J)
I have,cod the hawdam materials requirements under Chapter 6.93 of the
Califomia I leallh&Safety Code.Sections 25505,25533 and 25534. I understand that er
QO
ifthe building does not cun,ntly have a mnam,that it is my responsibility o notify the 1 I1 n
occupant of the r rements which mustbe met prior o issuance of a Ce .1 of Ca I y J
Occupancy. /d: 9 7g �
Owneroraathon agent i Dam TOTAL: ISSUED BY:
OFFICE