25637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
IL.M.. - ZECTRRrcz PERMT O.
BUILDING DIVISION APPLICATION/PERMIT PLUMHING-MECHANICAL
F7777777U
25637 JvJ
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITI'ALDATF.
UNIT# LOT#
O RS NA F,: PHONE' CONTROL CO CfOR'S TjQME� CNO: ` -a a
Q
ARCIIIT IiCI'/ENGINEER: / LIC NO: ADDIS v
(o2os6eaK Aga
CONTACT: PHONE: cr `?l `figv, sr .5'HIf16UING PERMIT INFO
L / �Jl—�' Q�Yi.1EF,LEC'I'RIC PERMIT - PEE .
C#Ir Y�I�pSQs $ O 1 l PERMIT ISSUANCE BLDG ELEC PLUMB MECIi
nd N F )4 X
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mwz Ihereby affirmthat l am licensed underprovisionwfChapter9(commencingwith
w100 7000) of the Business end l4ofessionx Code.and mylicense ie in PANELS K%r �W.-W.
V,1`Aq,
ty UW Lie tares ata ercem. Jrq# .1y `` ♦l
¢ZtY License Class Lim.If ' J UP T0200 AMPS
y6y
Did, Common, 201.10010 AMPS
Z0soz ARCHITECTSD RATION OVER 1000 AMPS SQ.lel'.FLOOR AREA $/SQ.tT.
C 1 unJemmnJ my plana shall be used as public mods.
FN W SIGNS ELECTRICALf�— ilNALED IN *
Qy � Licensed Professional / Ips IpI �1ry�' pP��
4X4e4L V OWNER-1 hereby affirm i rt,I not exempt frmDER o he Cmannefor.License Law far the TION SPECIAL CIRCUIT/M1SC. I vj P U Y C�
W34.y following acs...(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
tg EI0 which manes a permit to concoct,otter,improve,demolish,or repair any structure
Wn�;p priorm its issuance,also raximm me applicant forsuch permit to file a signed statement POWER DEVICES DAT (�l�
p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
t U 9(commencin (h Section Y000)ol'Division 3 of me Business and Professions Cade SWIMMING POOL ELECTRIC
ce (commencing ) VALUATION
n]_m or Oat he is exempt hemfmm and the basis for the alleged exemption.My violation of
Section 903 L5 by any applicant for a pewapplicant OUTLETS-SWITCHES subjects the applican
o a civil penalty of Q #
nor nom floor Ovohundre ny,oTmye00}' NEW RESIDENTIALBLECTR _SQ.IT.
❑ I,the wnemHhepmpeny,armycmtendedwimwel for he(Sec.compensation, STOkIGS TYPO CONSTRUCTION
a3— will dothewons aidfireThe ontisnot'ntendWoraffared for not
90a4,Business
and Professions Cale:The Contractor's License Law such
not apply to an owner of
ownenywhob,provii impmvuchereon,vemensamm and won does achwork hlmsllbnhmu e.M1is
employusilding rimprove impmvemwithin not imeolfcomoffered forWe.Tr- OCC.GROUP ERESUNITShowevepillhathe vl(Ile arden(if emem lamldedid inneyemor improefor purpose fTOTAL: aro
builder will have the harden of proving that he JiJ nt buil]nr improve for puHnse ofnleJ.
❑ Lasowncrofrhepmpeny,amexclmivdyconaactingwimlicensedconwnorsm �: LUMPING PERMIT PEE FLOODZONI?
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not applyto oaownerofpmpeny who builds or improves therenn,and PERMIT ISSUANCE
who nmtmcm for such projects with a connections)licensed pars prom to the Conwemr's N
License Law. ALTER-DRAIN&VENT-WATER(EA) 3.�V FEE SUMMARY
❑ I um exempt under Sec. ,B at 1'C for this reason HACK FLOW PROTECT.DEVICE I SIDE. I:F.S
SANITARY Y N
Owner Data RECEIPT#
TRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DF.toself ION SC11001.TAX Y N
❑ Ihertby alfwthatlhnvee ccnificam of cnnunno ulfZone,.'attnificate of RP,CFIPI'#
Workers'Compensation Insurance,or o certified capymereaf(Sec.3ipX.Lab CJ which IT%TURPS-PFR TRAP 6 U PARK FEE Y N
covers all employees ander this pewit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FEE
❑ Ceamfiril copy is hereby famished.
❑ Cenified copy is fled with the city inspection division. GREASHjINDUSTRL WASTE INTERCEPPOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissardmi need am be completed ifthe pe wit is borons hundred dollars($10(y) SEWER-SANITARY-STORM EA,200T. ENERGY FEE
orless.)
I certify that in the perfowancea(Newark forwhic thispfwit is issued bell WATER HEATER W/VENT/RLECR
not ennploy any perso n as ee c o me Workers' s PAID
o z Comp nantion ^r o WATER SYSTEI UTREATING Date Receipt#
NOTICEtT hCA NT;If,afterm ing this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
rrA. become subject to the Worker's Compensation provisions of the Labor Code,you must M
�i ? forthwith comply with such provisions or this pewit shall be deemed revoked. BUILDING FEE w
CkI r� CONSTRUCTION LENDING AGENCY SEISMIC FEE r
z I hereby affirm that mere is a construction lending agency for me performence of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ,m ELECTRIC FF,Ii
�.I I.code,a Nnme 77# v j v+';,,:s - +'f fO
Landers Address QTY. : S° MECHANICAL PERMIT A' :BCE= PLUMBING FIi9
U 1 certify that I have read this application and sure that me above connotation is MECHANICALFEE
7" correct.I agresto comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE aft #
building construction,and hereby authorize represenmtiresofthis city to enter upon the CONSTRUCTION TAX
U ,z above-mentioned property for inspection amposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep homeless the City of Cupertino against
liabiliticx,jm` etas,cost mad expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in comequ a the ting of i mit. AIR HANDLING UNIT(OVER 10,000 CFM)
4flIffoue-of Applicanl/Cothacmr, Dac EXHAUSTHOODDYMUCf) 6. O PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10(1,000 BTU) Date Receipt#
Will the optimum or future building occupant some Or handle fimadous material ❑EATING UNIT(OVER 100,000 BTU) 'I'OTAh:
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scai Via; ❑No 1T
El VENTILATION FAN(SINGLE REBID)
❑Y
BOILER-COMP(JUT OR I W.001)BTU) lISSI�APLCEDATE
Will me applicantorfame builaingoccupant useegaipmentordeviceswhichimit P H �J
nutritious air contaminant.as defined by the Bay Area Air Quality Management BOILER-COMP(OVER• 1110,000 BTU)Dinner? 1
❑Yea ❑Na NEW RFSIDENDAL M[CII. C SQ.IT. OCT +f� 1JJo0
3
1 have read thn hazardous mammals requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand mat
if the building does not currently have a¢nam,On,it is my responsibility to notify the CII-I Ur UUrrh 11140
occupant of the requirements which must be met prior to issuance of a Certificate,of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE