25521 APPUCANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO - CA7 - PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION _IIUIIAINO PROJECT IDRNTIFICATI(IN 25521
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
/ 0505 1 L L /14 Va- UNITO LOT,,
O %�N�li:� �� PHONl3: CONTgACI'pR'$ M LIC NO:
NIC CONTROL
11//llll V OF CV O CW
AKCHITECUENGI 'ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: "
QTY. ELECTRIC PERMIT- p+4 v'.'"^ 'a? " 1,','yljjLDING PERMIT INFO
1„A„`.F PEE
BLDG ELECT PLUMB MECH
PERMIT.ISSUANCE 1:1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
1402 Ih7000)ofDiNull 3 ofm Bussedl iness
and irfesions Corer9(commencing with
�i100 Section 7000)of Division 3of Ne Business end Professions Code,and mylicerue it on ppflEbg 1
wufull force ondcffect.
F zUW Lt..Class Lic.p UP TO 200 AMPS
r.6y Dare Convenor 201-1000 AMPS
Z8,8,vOK ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA VSQ.IT.
Q 1 understand my plans shall be used or public ra mU.
u7 SIGNS ELECTRICAL
Q,7_5 Licensed Professional
�m< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaU 1 hereby amw thus 1 that exempt from Ne Commences License law for the
tal3uv following mason.(Section 7031.5,Business and Professiws Cade:My city or county TEMP.METER OR POLE MST. `^
��-01 which requirer apemdt to commuct,alter,improve,demolish.or repair enyrwnurs
MEW;� priorto its issuance,alpursuso require Ne applicant(orsuch permit to file argued moment POWER DEVICES
m K O Nat he is licensed mst to thns e provision of Ne Contnm
cre License Law(Chapter
aXo 9(romwncingwim Section7(100).(Division 3.fine Business and Profemionr Code) SWIMMING POOL ELECTRIC VALUATION
w or he isexempl therefrom and the basis forme alleged exemption.Any violation of OIIILETS-SWITCHES-FIXTURES
FZ� Section 7031.5 by any applicant for.pemtit subjects Ne applicant to a civil penalty of
1'2
.^m than five hundred dollen($300). NEW RESIDENTIAL ELECTR _SQ.FT.
mto 1 sowneroflheproper menycmployaswith wegestudmirsolemeopeosNon. STORIES TYPECONSTRUCTION
tau it the wmk,and the structure iaaotintndedoroffered forsale(Sm.7044,Business
N
Profess ns Code:The Conwetors License Law does not apply to an owner of
ropenywhobuddsorimproves shcnon,and whodoessuch work himselfor throughhie OCC.GROUP RES.UNITS
ownemptoyas.providedthatsochimprovemmtsmnotinteM mofferedfor We.IL
however,she building or improvement is sold within one year of completion,she owner.
builder will have the burden of proving that he did not build or improve for purpose of
le.).
❑ huowner of the property.emexclusively contracting with licensed contractors to Qom' PLUMBING PERMIT PEE FLOOD ZONE APN
construct she project(Sec.704th.Business and Prafeuionv Cede:)The Connector's
License Law does not apply to an owncrmfpmperty who builds or improv,,mereon,and PERMIT ISSUANCE
who conwcu farsuch projects with acontreaor(s)licensed ponuant tuft Contommua pLTP.R- AENT- AEA
License Law. DRIN&VWATER( ) FEE SUMMARY
It t am exempt uoder Sm. ,B&P C for this mason OUTSIDE F
BACK FLOW PRO'T'ECT.DEVICE SANITARY Y N
Owner Dam RECEIPTg
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihembyaffirm that l haveacenifcateofcomenuoself-insum,orecenificateof FIXTURES-PERTRAP RECEIPTg
Workers'Compensation Insurance or a certified copy themof(SecJSW,Lab C.)which PARK FEE Y N
covers all employee's under this pewit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy It BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
CI Certified copy Is hereby furnished.
❑ Candied copy is filed with the city Inspection division. GREASIJINDUSTRLWASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section needrm be completed ifthe pewit is future hundred dollers(SIW) SEWER-SANITARY-STORM EA.200171'. ENERGY FEE
or lase.)
I comfy that in the performance of the work for which this pewit iaiuued, 7lll1l1 TE HN NT 8
not employ any penan in any manner eo m m becoma subject In the W�rrx'h : PAID
Compe...thm Lawsof Califamia. Data—
z
A S Ev T Dme RaeiplN
z Applicant `1
7 NOTICE TO APPLICANT:IL after making this Cenificme of Exemptionyou sed -,�/ rN :SID AL M SQ,FT. TOTAL:
�^. > banana subject m the stmpr Compensation provisions of Tho Cede,you muss
foMwifh comply with suchis provisions or This pewit shell be domed
revoked. D -- BUILDING FEE
h] — SBISMICFEE
ass A7-. CONSTRUCTION LENDING AGENCY --y -
5 I hereby affirm Netters ss a convection lending agency for the performance of
the work for which this pewit is issued(Sec.3097,Co.C.) TOTAL: ELECTRIC FEE
Lenders Namey
4. L^ Lenders Address QTY:,-" ' MECHANICAL PERMIT PCG ; PLUMBING FEE
0 W 1 comfy that I have read this application and auto that me above informer MECHANICAL FF.P.
I. '
r7° C1. ct l agree to comply wit i city and county ordinances and sum laws relating tPERMIT ISSUANCE
correct.
tiU) building convection,and hereby summon representatives ofshis city tomer upnnihe
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
C7 (We)agrm to save,indemnify and kap harmless the City of Cupertino against
liabilides,judgments,costa todexpames which may in my way accrueagainst mid City AIR HANDLING UNIT(TO 10,000 CFM)
in e goofing of mi e it. 9 (gAIR HANDLING UNIT(OVER 10, O CFM)
S
S' to f pbuam/Comrannr Data EXHAUST 14WD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE I MATING UNIT(TO IW,000 BTU) Date Receipt#
Will me applicant or future building occupant at=or handle huaWon=,coal
as defined by the Cupeoina Municipal Code,Chapter 9,12,and the Health and Safely HEATING UNIT(OVER I W.00)BTU) TOTAL:
Code,Section 25532m)?
13 Yes ❑No VENTILATION PAN(SINGLE RPSID)
ISSUANCE 6ATE
Will the applicant orfmunbuildingacupam uoequipmentordeviceswhich nrdt
BOILER-COMP(311POR IW,WO BTU)
loomdous air contsmmenu or defined by the Bey Am Air Quality Management BOILER-COMP(OVER• 100,000BT0) -
District?
❑NW P A I D
No NEW RESIDENTIAL MECH. SQ.FT. Ce
I have read the hewdous metedols nquimmems under Chapter 6.95 of she P - 3-199
California Health&Safety Code,Sections 25505,25533 and 25534. I understand met SE
if the building does not currently have a tenant.that it is my responsibility to notify the
occupant of the requirememr which mut he ren poor m issuance of a Cmlfcam of /x y
Occupancy. V 1 l 1 V 11 w.
Owner or auhodud agent Date TOTAL ISSUED BY: