25675APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOrL
APPLICATION/PERMIT
'HmLECTF iCAL
PLUMBING. MECHANICAL
P17RMI'I NO. g�
2556755
BUILDING DIVISION
BUILDING PR(1JRCT IDENf11HCATION
�J
ILADDRESS
SANITARY NO. APPLICATSUBMITTAL DATE
/DING
n�
(Ow �'c,ia C—. A�Le I
UNIT#
LOTH 0 g
TIION
DAG
O f:RS NAMC: PHONE:
CO
RA Cf R'SN M& LIC NO:
'silk 4"380-)3, s3 4o
N/C CONTROLN
A CIII'IECTIENGINEER: LIC NO:ADDRESS:
❑
CONTACT: PHONE:
QTY.
ELECTRIC PERMIT FEC
BUILDING PERMIT INFO
•
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
A ❑ ❑
JOB DESCRIPTION
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l an licensed under provisionsol'Chapmr9(cotmmencing with
Section]000) of Division 3 ofthe Business and Professions Code, and my lease is in
PANELS '
full fora unit effect.
License ClassLi,#
U1`T0200AMPS
PTO
�- s r
Date Contractor
201 - IBM AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FF.
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
�a
SIGNS ELECTRICAL
-L/.•
Licenud Professional
OWNER-BUILDERexemp
SPECIAL CIRCUIT/MISC.
1 hereby affirm Net I am exempt from the Conwctura law for the
n the Caron
followingreason.7031.5, Business Professions Code: Any city or county
e: Any
TEMP. METER OR POLE INST.
which
which aper it to
s a permit m construct, urn improve, demolish,
improve, copula any structure
d. itua pemtitt.s fi statement
pat icensed,ulaont tprvisios
POWER DEVICES
of the Co
he is
thatheis licensedpuauant to the the Contractors License Law(Chapter
9 on 7theprevisionsof
(commencing aW) of Division the and
withtherefrom
len9 Cartelof
SWIMMING POOL ELECTRIC
UAor ;I "
.Any
tthereplicannd the baspermitorthealleged exemption. Aivilcaualty of
that h exemptthe ed exemption.
xem
Sectio 7131.5 by
Section ]U31.3 by any applicant for a permit subjttm the applicant m a civil penalty of
OUTLETS - SWITCHES - FIXTURES
.�l �
oat than Eve hundred dollars ($500).
rofthepmpeny,ormysmployces with woguustheirsolecouncam non,
NEWRESIDENTIAL ELECIR _SQ. Pf.
STORIES 'TYPE, CONS'1'RUCI'ION
11 do the work, and Lha mmt wee is unintended or offered for wk (Sce. 7044, Business
it Professions Cale: The Contractor'a License Law does not apply to an owner of
ropeny whobuildsor improves thereogand wbodoasuchwork himmulforthmugh his
own empluyces, provided that such impovememe arc not intended or offered for sale. IL
OCC GROUP RES. UNITS
however, the building orimpmvement is sold within one yearofcompletion, the owner-
1:
builder will have the burden of proving that he did ant build or improve for purpose of
^
rule.).
QTY.
PLUMBI GPERMIT $�
FI. DZ.ON. APN
❑ I, us ownermfthepmpcny,em exdusivelyconrrating with littnre0 conuecmnm
hn project (S. 7044, Business and Pmhssim e, Gods:) The Comzaetor's
.ourut tec
` �J'
eon,nd
ownofpropa ory who builds impmvasthere
License Undies;not opplyta uaer
1'ERMITISSUANCE
whmconimetsforsuchpmjeatswiihaconuactor(s)licensedpunumuo the Cmntructora
ALTER -DRAIN VENT- ATIIR(IA)
License law.
FEE SUMMARY
❑ I em exempt under Sec. , B & P C for this reason
BACK Fl.OW PR ECT. DCVICE
DRAINS- FLOOR, ROOM, AREA, COND.
T 1
SANITARY Y N
RHCEIPI'q
Owner Data
WORKMAN COMPfiNSATIONDECLARATION -
SCHOOLTAX Y N
❑ IheCompe that lheveaceni conunnrself-Insurc,m aarC.)
FlXTURPS- PER TRAP
RI?CF.IPfN
cans' Compensation lmuranceora certified copy thereof (Sec. 3800, Lab CJ which
certified
a which
PARK FEE Y N
vera all ployae'o mdembis permit.
GAS - EA. SYSTEM -1 INC.4 OUTLETS
RECEIPTp
y
BUILDING DIVISION PEES
..CompnnY
GAS - IA. SYS ITM.OVER 4 (EA)
PLANCIIECK FEE
❑ Cer ifiedcopy iehembyfumished.
GRFASERNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed wit the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS ME
COMPENSATION INSURANCE
SEWER - SANITARY - STORM PA. 2MIF T.
ENERGY FEE
(FIissection need not he completed ifthe permit is Room hundred dollero($100)
others.)
WATER HMATFR W/VENT/ELECI'R
I certify that in the performance ofthe work for which this permit is issued, I shall
not employ any person in my mndaer so u to become output to the Workers
PAID
Compensutionlawsof Califnam Date
WATER SYSTFM/fRP.ATING
Data Receiptp
Applicmt
NOTICE TO APPLICANT: If, after making this Cerificate of Esemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provision of Ne labor Code, you must
forthwith comply with such provisions or this permit shall to deemed revoked.
BUILDING FEE
SEISMIC FEE I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
ELECTRIC FEE
Lendsea Address
QTY.
MECHANICAL PERMIT PER
PLUMB-01EC
I certify that I have read this application and stare that the above information ie
torten. l agree to comply with all city and county ordinmces and stem laws relating to
PERMIT ISSUANCE
MECHANICAL IBE
building construction, and hereby authorize repreacnmrivesof thiscity in interaction the
above.mentioned property, for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCf10N TAX
(We) ague to save, indemnify and keep homiest the City of Cupertino gum,
liabilities. judgments, costs and expenses which may in any wayuccme against said City
AIR HANDLING UNIT(TO 10,0(0 CFM)
in consequence of ting of 'a rmit.
40 L7 93
AIR HANDLING UNIT (OVER I0,000 CFM7
EXHAUST HOOD(W/DUCT)
'92
ignuturemf App' t/Cma r ate
PAID
HAZARDOUS MATERIALS DISCLOSURE
I IEATING UNIT('I'(l loo,IXIB BTU)
Data Receipt#
Will the opplicam or future building occupant store or handle hamrdous material
as defined by the Cupcnino Municipal Code, Chapter 9.12, and the I batch and Safety
HFATING UNIT (OVER I W." BTU)
Cala $<CII 25533(x)?
CI Yea 11 No
❑
VENTILATION PAN (SINGLE RESID)
ISSUANCE DA
Will theepplicantorfuturcbuildingacupum uxequipmenmrdeviaswhich emit
BOILER - COMP CHIP OR 1(0,1010 BTU)
tauNons air constituents es defined by the Bay Arca Air Quality Management
reactions
BOILER - COMP (OVER 100,000 BTU)
yy
Y
❑Yes EI No
NEW RESIDINTIAL MECH.—SQ. FT.
1 have read the humrdous materials rcquircmems under Chapter h95 of the
03
Cdifomis I health & Safety Code. Sections 25505, 25573 and 25574. 1 understand that
®pp
if the building does not currently have a center, that it is my responsibility to madly the
oecupam if the ".hemems which most be met prior m ismance of a Cenificam of
O nllnlfh
occupancy.
11y �ur
' 1
TOTAL:
ISSUEDBY: `-'✓� • /
Owneroiamhoriud agent Due