25056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOF'CUPERTINO OEltif�ialic IRI A FRESH NO.
f6' , APPLICATION/PERMIT PLumBINc-MECHANICAL 25056
k—_ P"ILDINC DIVISION BOILDINGPROJECI IDENTIFICATION
.+•?-l-'-�BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
tJ'N�'✓'V UNIT# LOT It
WNERS-AME- PHONfr. CO TR CTOR'S NAME: LIC NO:
` S Oft N/C CONTROL#
.RCH19TCf/ENGIN LICNO: L_ ADDRESS: ❑
2
CONTACT, PHONE: -
QTY. ELECTRIC PERMIT - FEE BUILDING PERMIT INFO
BLDG EL PLU d MGCFI
PERMIT ISSUANCE '�� I(.��F
LICENSED CON'IkAC']'OR'S DECLARATION APPLIANCES-RESIDSNTIAI, JOB DESCRIPTIONyy I hereby affirm that l am licenced anderprov[slons mChooder9(commencing with _
00 Secton7000)mDi,vmr3.f0e Broin—and Profesaionn Cede,andmy license is in PANELS
U111force and effect.
Lic.#
,Q, License Clns !7 r-, UP TO zoo AMPS
Date C.ntm+or 201-1000 AMPS
FO h mA CIIITECT'S DECLA A 10 OVER 1000 AMPS _ SQ.FT.FLOOR AREA $/SQ.IT.
OZ'-'Q l anderand my plans shall be used as publiorevends.
r 4�w SIGNS ELECTRICAL
Licensed Professional
ew OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 beeryaffirm thpt at 1 am exemfrom the Comruclor's License Learfor the
MC, fmlowing rea on.(Section 703 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. -
�1�1 which remims a permit to construct,cloth,Improve,demolish,or repair any structure
"`� "matt i>snunce,ulxn requires@eapplicam for such permiun fileesigned staameno POWER DEVICES .
qp that he is licensed pursuant m the provloare,of the Contractors Li.ense Law(Chapter _
aM0�' 9(commmaciag with Section 9000)of Division 3o fine Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
P]
''+yX1C ern onhao he is exempt therefrom and the basis for themleged exemption.Any vioI I V
t,-4,} Section 9031.5 by anyapplicam for a permit subjects the applicant in a civil penallyof OUTLETS-SWITCHES-FIXTURES AL � `
not more than hundred delta,, J
��O an fiun / 01),trKc ❑ I,nsownertuRhe property..rmyemploywe with wegrsesthcirsolewNEW RESIDENTIALELECTk Smpenemion, Q'FT. STORIES '1'YPB CONSgRUCq'ION
y�� will dolhewonsamde:Themureianmimend.derm'wdoes notapplyt an Business
and Professions Code:The C,duan,',Lianas Law does not apply m nil owner of
ownpropenywyeer,pdsorimpmvesch improvements
whs menet inandech himeafonhroughhis -
employeoe,provided thmsuchimprovements are notimendedmofferethostile,If. WE C
NII'
howeveriJI have the burden
ofpmentissathe(lidnot build or improeforpe.wner TOTAL: �.7
builder will have theburden ofproving that he did not build or improve[.r purpose of
s:de.L - QTY. PLUMBING PERMIT' PEE [ N.
'❑ I,as�wnernDheproperty,am exclusively contraming with licensed commmonm (/
constraint the projem(Sea.]044,Business and Prafeasnns Cade)The Coutmetora �D a
License Law does amapp]y mamnwnerufampeny whobuildtiminhmves there..,and PF.RMI'I']SSUANCE V qTE
echo wnLathsforeuch pmjeclswithnwmmdnr(s)]Icensed pursuam to the C.mmet.rs AI/II?k-DRAIN&VENT-WATER BA
Llcanso Law. GIA) - FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
,Owner - - Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIVE'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherehy efOrm lhnllbuveacenificam of consent mself-insurq oraconidcme of FIXTURES-PER TRAP ,,'1i RECEIVE'#
W.rkern'Ghmpensed.,lnaureneo oracen Bed wpythere.f(Sec 7900,Lab CJwhich SOI/ PARK PEE Y N
coversall employee's under this pemhil. GAS-EA.SYSTEM-1 INC.4OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
CenifieJ copy is hereby furnished. GAS-Eh SYSTEM-OVER 4(EA) PLANCHECK FEE
❑' '
® Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - CREASE.TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectio.noed no,bec.mplecd ifthe pamth is fortune hundred dollars($100) SEWER-SANITARY-STORM F.A.200FP. ENERGY FEE
or less.)
I certify that In the performance of the work for which this permit is issued,I site][ WATER HEATP.R W/VENT/ELP,CPR
urn employ any person in say arcane,so as 1.become subject to the Workers' - PAID
Compensation LawsmCuiif.mia. Data WATER SYSTEMITREATINC
O Applicant
Date keccipt#
O
NO'TICEI0 APPLICANT:If.after rakingthis Ceniticme of Exemption you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
cO hecoma subject to the Worker's Compensation provisions of the Labor Code,you must
� 1 forthwith comply with such previsions or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE TAT
1 hereby affirm that there is a construction lending agency for the performance.[ 'TOTAL: U-�
U O 11.work I.,which this permit is issued(Set.3099,Civ.CJ ELECTRIC PEE
Lender's Name
Leaders Addmsa QTY. MECHANICAL PERMIT FEE PLUMBING PEE
I certify JV SVVIS
e to c have read this application and state Elmo the above laws
elating is
'"I a
correct.]agree to comply with all city and county oNinances and slate laws relating to PERMIT ISSUANCE U MECHANICAL FEE rl T
building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX oC V
U 7 above-mentioned progeny for inspection purposes. ALTERORADDTOMECIL'
.7 (We)agree to save,indemnify and keep harmless the City of Cupertino against -
llubiliiegjudgmems.custs and expenses hKr-_._y,1n any Wayne...on ainstsaid City AIR HANDLING UNIT(TO Ino00 CFM)
in c cel the granting oRhis permi
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor D6 I EXHAUST GOOD(W/Dl '
PAID
HAZARDOUS MATERIALS DISCLOSURE BEA'[NO UNIT TO 100,000 BTU) Date Receipt#
Wili Ne applicmt or femre building occupant store art handle hazardous material HEATING UNIT(OVER 1010,0010 BTU) TOTAL: 2,15-
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I Ieahh and Safety
Codec,Smolon 25532(a)P
11 Yes ❑No VENTILATION FAN(SINGLE RESID)
HOILER-COMP(3HPOR I100ifu TU) ISSUANCE DATE
Will lair emleanmores as building by the Bay A .Air loudeor devices anagement -
Insider? pair wnmminnnrs as define)by the Bay Arae Air Quality Management BOILER-CAMP(OVER Io0,000 Bq'
DistridR i N
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. i� i(](iQ
Lhavc road the hazardous materials requirements under Chapter 6.95.f the /{�. 0 'JJJ
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that to is my responsibility m notify the
oecupam of the termun mems which must be mat pd.,to issuance of a Cenilleale of 'VII 1'ur k urGE11(poll
Oern ancy.
Owner or authorized agent Dale TOTAL: �l, ISSUED BY: U""
OFF