25167APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
APPLICAT ION/PERMIT
'T:=EIa,.1MTCA
PLUMHIN;-MECHANICAL.
PERMIT No. 25167
BUILDING DIVISION
BUILDING PROJECT IDENTIF'ICAT'ION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUIIMITTALDATI.
UNIT# LOT# '
OWNS AMG: PHONE:
NTRACfOR'S NA (CID0.
NIC
CONTROLM
�_/C
❑
ARCHITIiC'I'/ENGINEER: LIC NO: RFS: , I /�
CONTACT: PHONE:NtEtC
: 3'.�', ; .. .
QT,Y. :75., k 1 tELE&RIG:PERMITa EEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
#4t'^9�'4'6&A'T'i'v
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
I hereby affirm that I am licensed underpmvisionaof Chapter9(commencing with
Section 70)10of Division 3.f the Business amPmfesaloms Cede,end my license is in
PANELS
full fomeandef�v. 03S
License A. Lic.p
UPT0200AMPS
Dam con
201 - 1000 AMPS
SQ. FT. FLOOR AREA
8/SQ. FT.
ARCITITECT.1 DF.CLARATIO
OVER 1000 AMPS
1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUTDMISC.
I hereby affirm that 1 am exempt from the Contractor's License Law for Ne
following mason. (Section ]03L5:Business and Professions Code: Any city orcounty
TEMP. METER OR POLE INST.
which requbex a permit fo cunsvucb alter, improve, demolish, m repaif any,.cturc
Met to its issuance, also requires the applicant fursuch Permit o file a signed statement
POWER DEVICES
that he is licensed p earn t to the provisions of the Contnetor's License Law (Chapter
VALUATION
9(commencing with Section 700B of Division J ofthe Business and Pmfessios,Cade) SWIMMING POOL ELECTRIC
or Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
OIITLEI'S-SWITCHES-FIXTURES
�.
Section "(031.5 by any applicant for a permit subject the applicant to a civil penalty of
nal mu re dmo five hundred dollars ($500). '
NEW ELI=R _ SQ. FT.
TYPE CONSTRUCTION
RESIDENTIAL
pinyeexwllM1 wages as eirsolecompensadon,
❑ I,asownernflM1cpr.perty..rmycmN
will do he wufk, and rhestruaure is not intended.,offered for sam(Sec.7044, Business
and Professions Cade: The Contractors License Law does not apply to an owner of
I'
I�aSTORIES
' A e
II J 0 V
propmywhu Indicsorimpowes Nerton.ml whodoe such w.rkhi eselforthroughhis
-
-OCC: GR
RFS. UNITS
own employees, Provided that such improvement am not intendedoroffered forsale. If,
-
however, the buildingor improvement is sold within one year ofcompletion, the owner-
IOTA 2 �� I' j
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
QTY, ERMIT
QTY. P�'
APN
[3 LazownerofNe propeny,em exdusiv<IY convecting wird licensedconvectonto
consumer the project (Sec. 7044, Business and Professions Code:) The Convector's
License Lawdocsnotapplytoanownerofpropenywhobuildsorimproveuhereon,and
PERMIT ISSUANCE
whocontmcts forsuch projects with a convectors) licensed pursuant"'the C.nvenm's
ALTER -DRAIN & VENT -WATER (EA)
FEC; SUMMARY
License Luw,
❑ IumcumplunJer Sec. , B& P C for this ..a..
BACK (LOW PROTECT'. DEVICE
OU I'SIDE FEES
SANITARY YN
RECEIPT#
Owner Dare
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND.
SCIIOOLTA% YN
r (hereby affirm that l haveacenifieme ofcoment to self-insum, or a certificate of
FIXTURES - PER TRAP
RECEIFTp
I PARK FEE Y N
RIiC
Workers' Compensation Insurance or acenified copy thereof(Sec. 3800. LubCJ which
Covers all cme 'spinyumdcnbis permt.
Paley #
GAS - IA. SYSTEM -1 INC.4 OUTLETS
I SIO
BUILDING DIV SION LEES
Compmy
GAS - EA. SYSTEM -OVER 4 H1O
PLANCIIECK FEE
❑ per5ral copy is hereby famis ed.
GRADING FEE
Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR
CERTIFICA'I'F, OF EXEMPTION FROM WORKERS'
GRCASHI'RAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section need not be completed if Ne permit is for one hundred dollars($100) SEWER -SANITARY -S'r ORM FA. 200FT.
or las.)
I certify that in the pertonunce of the work far which this permit is issued, I shall WATER HEATER W/VENT/ELECTR
has employ any person in any manner m as to become subject to the Wofken'
PAID
Compensation Lawsof Califomia. Date
WATER SYSTEMMEATING
Date Receipt
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESI DENTIAL PLMIL SQ, FT.
TOTAL:
become subject to the Workers C.mPcnsauon provisions.(the Isbor Code, you must
fowith comply with such provisions or this peit shall he deemed rtvoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perRmnance of
the work for which this rmit is issued(Sec. 3097, Civ. CJ
pe
TOTAL:
ELECTRIC FEE
lender's Name
Address
QTY. MECHANICAL PERMIT hliii
PLUMBING FEE
1 certify that 1 have read this application and sum that the above infonnNan is
MECHANICAL FEE
nen. I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
building construction, and hereby aothudee represenmtivee either city toenter upon the
CONSTRUCTION TAX
aMwc-mentioned pm,cny for inspection purpo.acs.
ALT17R OR ADD TO MECH.
(We) agree to save, indemnify and keep harmless the City of Cupcnino against
liabilities,judgmenta,wst ande.'resAwhichinarymarntrocaurear,arimismilCity
AIR HANDLING UNITOO 10,000CFMJ
' coasequenccofthe geantingof Ni pc ir. r��93
- AIR HANDLING UNIT (OVER 10,000 CFM)
PAID
Signature nl Ap A nntm<t Date EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 10(1,000 BTU)
Dote Receipt #
T L:
Will the applicant or future buildingmcupmt store or handle hazardous material HEATING UNIT (OVER 100,1%Ip BTU)
as definN by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety
Calc, Seen,,. 255J2(a)?
Cl Yea ❑ No
VENTILATION PAN (SINGLE RESID)
ISSUANCE, DATE
BOILER- COMP (311P OR 100,000 BT' U)
Will theapplicanmrfumre building occupmn useequipmemordeviceswhichemit
I
hazardous air comanummus as defined by the Bay Ana Air Quality Management
Disa st?
BOILER -COMP (OVER 100.1100 BTU)
A
i'
Ycs No
13 YesMECH.-SQ.
NEW RESIDENTIAL MECH. SQ. FT.
{// O
s
1 have read the materials under Chapter of the
1)
`
5505,ctnent
felly Cons
understand
and 255J4.Iundcrsmndflim
/c 1,9
ifthe wilding oesSafetyCwyhaveiamstthtitis
iccupanil nor thin it is my muance Car
which Certificate of
occupant .f the requirements which must M mer prior to issuance n(e Cerdficem.f
of the req must Is, of a
rr
O
Occupancy.
�
ISSUED BY:
Owner or authorized agent Dam TOTAL: