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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
<177I:BINi.1,1T HIAllPERMIT
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDE N'1'IPICATION
NO. 25001
BUILDING ADDRESS:
2MLcev&•may^ UNIT# LOT#
SANITARY NO.
APP1LICATIONSUBMITTTALDATE
`
OW RS NAM ` PHONE:
40
expa
RACfOR'S NAME: #� (.ICNO:
aise
NIC
CONfItOLp
ARCHI rECI'"GINF.ER: LIC NO:
R S: wEl31GIACT:
a
PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INEO
BL F10 PLUMB MECH
PERMIT ISSUANCE.
LICENSED CONTRACTORS DECLARATION
1 hereby nffinIthat I E licensed uACTORvisDE of RATIO (commencing with
APPLIANCES - RESIDENTIAL
'rs'Do lu
gJP` ON
PANELS
Section RNllp of Uivisimn 3n11be Rosiness and Professions Code, anJ my licemeia in
,!'1{I,�#:•e�.A�-1,��S
effa
tr Ilas
s Lic.N AUP
TO 200 AMPS
Wi - 1000 AMPS
Dom Contraaor /!!]
A CHIIECPS DECLARATION
I understand my plans shall be used ar Public record..
OVER 1000 AMPS
SQ. PT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm thm I out exempt from the Contractors License Law for the
TEMP. METER OR POLE INST. -
following reamn. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to mounted, alter, improve, demolish, or repair any structure
Prior to its issuance, also requires the applicant for such permiuo file a signed summers
POWER DEVICES
that he is licensed pursuant o the Provisions of the Contracto's License law (aspect
9(commencing with Section 7")of Division 3 of the Business and Professions Code)
or that he is exempuhcrcfrom and the basis(or the alleged exemption, Aayvimlatioaof
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
SWIMMING POOL ELECTRIC
VALUAI'I(1N�
1 M ��
1 y
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars ($500).
❑ I,asownerofthepmpeny,ormyemploymswithwagesanheirsdecompensudon.
NEW ID _ WkE'D'R
STORI iS
'IYPECONSTRUCTION
will doth¢work,.nd the summre isnot invaded oroffered tonsil. (Sm. 7044, Braine..
and Professions Code: The Contractor's License Law does not apply to an owner of
t
property who buildsorimprovesthereon, andwhodoessuch work himselforthrough his
nemployced, provided that such improvernmaxamman immdidedoroffered forret¢, If,
OCC. GROUP
RES. UNITS
however, the building or improvement is sold within one year ofcomplaion,the owner.
Indictr will have the burden of proving that he did not build mr improve for purpose of
QTY' PLTMBINGP ._
❑ I,esownerofthe property.amexdusively conwcungwiNlicensed convactortto
FLOOD ZONE
pPN
enact the project (Sec. 70u14, Business and Professions Code:) The Contractor's
Litems lawdmes not aPPlytn nnownerofpropeny whobuildsw improvertheremn, and
PERMIT ISSUANCE
who contracts forsuch projects with¢comadwands) licensed pursuant to the Contractor's
Licex law.
nl
� . - DRAIN &VFM-WATER (FA)
FEC•SUMMARY
❑ am exempt under Sec. , B & P C fm this meson
BACK FLOW PROTECT. DEVICE
SANITARY Y N
RECEIPT N
Owner Dote
WORKMAN COMPENSATION DECLARATION
DRAMS -BOOR, ROOF. ARRA, COND.
SCHOOLTAX YN
❑ Ihereby off= that l have. cmiricme ofcordenrto self-insum, or a ttnificate of
Worken'Compenmtionlnsum ecoracenifiedcnpy Nemof(Sce. 3800, Lab CJ which
RECEIPT#
FlXTURES - PER TRAP
PARK FEE Y N
camera all employed', under this permit.
Policy 0
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
any
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
CeNEed copy is hereby famished.
GREASE/INDUSTRL WASTE INTERCEPT OR
GRADING FEE
❑ mimed copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FF.R
COMPENSATION INSURANCE
SEWER - SANITARY - STORM FA. 20017.
ENERGY FEE
This section need not he completed ifthe Permit is for one hundred dollars(SIM)
or less.)
WATER HEATER W/VENOBLECTR
I cenify@ot in the perfomunce of Ne work for which this permit is ismed, I shall
Mt unploy ony person in any a." so as to become subject to Ne Worken'
PAID
Cmmpensminn Lmaid[Ctlifomia. Data
Applicant
WATER SYSTEM/TRP.ATING
Dam Receipt#
NOTICETO APPLICANT. If. a Am making this Ceriftcam of Exemption, youshould
NEW RESIDENTIAL PLMIL SQ. f4.
TAL:
become subject to the Workers Compensation Provisions of 0m Labor Code, you must
forthwith comply with such proriiioms ace Bit. I aniuhall be deemed revoked.
BUILDING FEE
SEISMIC FEF.
CONSTRUCTION LENDING AGENCY
I hereby offirm that hem is a construction lending agency for the performance of
hwork for which this permit is issued (Sec. 3097, Civ. CJ
TOTAL:
ELECTRIC FEEte
Lender'. Nome
Lender's Address
QTY, MECHANICAL PERMIT FEE
PLUMBING ILP,
1 malty Nat I have read this .#plication and rude that the above information is
l agree to comply with all city and county ordinancea and nate laws relating to
PERMIT ISSUANCE.
MECHANICAL FEEcorrect.
building construction, and hereby authorive representatives of this city to cr ur upon the
above-mentionnl property for inspection purposes.
ALTER OR ADD TO MECII.
CONSTRUCI'ION'fAX
(We) ogme to save, indemnify and keep harmless the City of Cupertino.,,Ima
liabilities,judgments,costs and expenses which may in any waymcom against said City
AIR HANDLING UNIT (TO 111,000 CFM)
in corse ce of the gra of this permit.
si Z
mfApplicant/ontractor Dem
remlik
AIR HANDLING UNIT (OVER 10,(X10 CPM)
tly
EXHAUST HOOD(W/DUC)
PAID
HEATING UNIT(TO IW,IKKt BTU)
HAZARDOUS MATERIALS DISCLOSURE.
Data Receipt It
Will the applicant our future building occupenr sum or handle hazardous material
as defined by the C.,rdino Municipal Code. Chapter 9.12, and she Iluhh and Safety
HEATING UNIT 100,000 BTU)
O
VENTILATION FAN (SINGLE RISID)
Cade. Section 25532(0)?
❑ Ya ❑ No
BOILER - COMP (3I IF OR 100,001 BTU)
ISSUANCE DATE
A 9 D
WillthI,
BOILER - COMP (OVER 100,000 BTU)
maceatorfmurcitfineg by the
havNnua air conuminmm ss define) by Ne Bay Ama Air Quality Management
AnipmemQualit Management
District?
P P�
❑ Ye. ❑ No
1 have real the hazardous materials requirements under Chapter 695 of the
7 1
Ap 1,d` 271993 a 1993
NEW RESIDENTIAL MECH.-SQ. Fr.
California I health & Safety Cods. Sections 25505, 25533 and 25534. 1 undentumd that
il' the building does not currently have a tenant, that it is my responsibility to ramifythe
o ccupmt of the require manta which must he met prior to issuance of o Cerifil, of
fq� tar surra. 111,ku
Occupancy.
'• V
ISSUED BY:
Owner or umhnrized agent prat
TOTAL: