25446APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO'x ILDINO-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING: PROJECT' IDEN'UVICATLON
PFRMI'I'NO.
n [ /1 /I Q
G J 4 4 v
BUILDING ADDRESS: I--
!/x �' r UN R L09'k
SANITARY NO.
APPLICATION SUBMITTAL DAn-
PHONE
OWNIiR� PIIONI?:
T CT 'S NAME: LIC
NIC
/ ❑
CONI'ROLM
_
O
ARCHITECT/RqIN ER: LIC NO:
A DRESS: r /
U n
CONTACT: ` PHONE :
QTY, ELECTRIC I'F.RMfT FEF,
BUILDING PCRMIT INFO
BLDG L'LEC']' P MB MECH
1'ERMII'ISSUANCE
LICENSED CON'TRACTOR'S D17CLARATION
Thereby of Du ihat Iw am licensedinssadd rifesof sCoe, (commencing with
Section7000)addict Division]of the Business and Professions Code, and my license is in
APPLIANCES - RESIDFNTIAI.
TOR DESCRIPTION
PANELS
full force and effect.
License Class LIT.#
UP 70200 AMPS
201-1(00 AMPS
Dale Commuter
ARC] IT= S DECLARATION
1 understood my plans shall be used in public records.
OVER 1000 AMPS
SQ. IT. FLOOR AREA
E/SQ. FT.
SIGNS ELECTRICAL
11^tl'
Licensed Professional
OWNER -BUILDER
SPECIAL CIRCUIT/MISC. L„
rnDECLARATION
1 hereby uffimt that 1 am exempt from the Co sions Cs License Wan for ly
following reasnn.Igttllaa]tJ1.5, Business and ProPossions Cale: Any city or county
f"'� R
I
9'EMP. METER OR POLE ST , J
i. �� �J
witch itis, s n eemdi ac conswct, idler, improve, demolish, or repair any verdure
pastorsLifile. se staaveent
Nevisios fine
'02
POWER DEVICES
thiunoinicensed,ursuant to the Lo
Nm he isncingw pursuant m050)of Provisions the Ce Basin Contractors License Low (Chapter
Co
9 (commencing withSectionDivision the Professions Code)
v
SWIMMING POOL ECIRI(
VALUATION
that heir and the the do
ed exemption.
or Section h7031.5 by any tefroveand the basis
Station ]0 errartnhecta do,dexeveption. Any violation of
by any dam fora permit subjects Ne epplicmt to a civil penalty of
"
OU'T'LETS - SWITCHES - FIXTURES
alt hundred
to rt enthanevehundreddollars yempl
❑ f,asNwed
NE.WRESIDENTIALELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
do woaofthcostmew,orm.,inawdelm (sale (Sec. Business
will Jo the work, and a is nut intendede imitate lifted.
Thudure
Lawrdo
and Refashions Code The Contucmds License Law does to an
apply m on owner of
or
pmpenylobobuildsorimproves Nereomandwhodeansuchworkhimselforhro le.his
provemensatene can e
ever, I ded Natauchim t t t ddoreffered (ethnic. If.
OCG GROUP
RIiS. UNITS
TOTAL:
the buiprovi
the owner-
however, she banding order oEmem is hath withia did
of build of improve for
builder will have the burden of proving Net he did not build or improve (or purpou of
- -
9,1 Y.. PLUMBING PERMIT 17EE
snit.)._
❑ I,mowneronhepmpony,amexclusivelycontr tingwiNRcens cone torslo
MOOD ZONE
qPN
construct due prober (Sec. 71144, Business and Professions Cade:) no Conuuctor'u
License Law ducarmapply manownerofproperty, whobuildsor improves thememand
PERMIT ISSUANCE
who contracts forsuch projects with acenlmctor(s) licensed pursuant o the Contractors
License Law.
ALTER BA
I )
ao
FEE SUMMARY
❑ 1 an exempt under Sec. . B & P C for this rc um
BACK FLOW PROTECT. DEVICE
OUTSIDE
BEES
SANITARY N
RECEIPT#
Owner Dam
DRAINS - PLOOR,ROOI°. AREA, GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
❑Ihcreby tffinn Nm]havcacenificea of censer mself insure, nraurtificum of
Workers' Compensation Insurance or acertifed copy theref(Ste. 3800, Lab CJ which
RXTURPS-PI?R']'RAP
RECEIPT#
PARK ICE Y N
coven all employees under thisL
Lx^"'
Policy #
GAS - EA. SYSTEM -1 INC.4 OUTLETS
RIcCEIPTN
BUILDING DIVISION FEES
C Pant
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEL?
Certified copy is hereby famished.
GRFASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
Certified copy, is filed with the city inspersion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -STORM EA. 2WFF.
ENERGY FEE
(This se,.ww.iedwt be completed Hint permdiaforonehundeaddoears(5100)
or leen.)
WATER THEATER WIVENT/F.LECI'R
I certify that in The perfomtnce of the work for which this permit is issued, l shall
not employ any person to any manner so as to become subject to the Workers'
PAID
WATER SYSTEWI-REA']'ING
Compensation Lawsof California. Date
Data Receipt#
Applicam
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SO. IT.
TOTAL:
become subject to the Worker's Compensation provisions ofthe Labor Cole, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FL']?
CONSTRUCTION LENDING AGENCY
I hereby affirm Nauhea is a emomicusm lending agency for the pedometer. of
the work for which this permit is issued(Set. 3097, Civ. C.)
q 1'
ELECTRIC FEE
Under'Namc
I.caders Address
QTY. MECHANICALPERMIT - FEE
PLUMBING FEE/"'
I certify Nat ] have read this application and state that be above information is
comply with all city and wunty ordinances and state laws relmivgm
PERMIT ISSUANCE
MECHANICAL FEE
n, and hetebyauthodm mpmsentadves of Nis city m enter upon the
roperty for an,purpose,'.
ALTER OR ADDIG MECH.
CONS'IRUCTIONT
ifVelsex
1�,ja swhicM1 may many way accrues inns hu' City
AIR HANDLING UNIT (TO IQO(O CFM)
ore a hipermit.
ALR HANDLING UNIT (OVER 10,000 CFM)
0 ica^UConracmr me
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
PAID
Dole Receipt#
HEATING UNIT (TO I00,000 BTU)
Will the applicant or future building occupant were or handle harardoua material
as defned by the Cupertino Municipal Coda Chapter 9.12, and the Health and Safety
BEATING UNIT (OVER 100,000 BTU)
L:
Code, Section 25532(a)1
11 Yes ❑ No
VENTILATION FAN (SINGLE RESID)
Will the applicant rfumre buildingwcupunmuegsipmemnrdeviceswhiebemlt
BOILLR- COMP(JHP Oft IW,(KKI BU)
T
ISSUANCE DATE
BOILER -COMP (OVER 100,800 BTU)
hmanlous air conmminents as defined by the Bay Area Air QuAily Management
Dis ric(l
❑ yes ❑ No
1 D
NEW RESIDENTIAL MECH. SQ. Er.
I have read the hndead is materials requirements under Chapter 6.95 of the
California
ingdo&Safety CWe,Schotsoul,tht it is add 155M. Huy to rand Nat
yhave uroam,et itismyresponsibilityenmify the
ifthe haof
tdyesnotments
wcopam of the requirements which moat be met prior m issuance of a Certificate of
Occupancy.
ISSUED BY: 4ijjCI�II1vU
Owner nr umhoriaed ngrnt Ona
TOTAL:
OFFIUL