25516 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLEC'pRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING�MECHANICAL 25516
' BUILDING PROJECT HIEN9'IPICATION
BUILDING ADDRESS: `` /yy/�� / SANITARY NO. AAPPLICATIONSURNUITALDATG
ore L!"1V� Lei UNIT# LOT# f �2
WtRSNAME m P ONE: CONTRACTOR,S# E: LIE NO:
�i N/C CONTROL N
0AR 111'1'ECT/ENGI EBR: „C 0 ADL=S . ❑
CONTACT: PHONE: IF " BUILDING PERMIT INFO
QTY.11
'ELECTRIC PERMIT PEE
p-0 LGCT BCH
,NPLU❑MD
l-7x1v 0PERMIT ISSUANCE
LICENSED CONTRACTOR DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ilimb,affirm thall.m licensed underprovivions of Chapmr9(commenting with
6100 Section 90(m)of Division 3 of the Business and Professions Code,and my license is in PANELS
aWF toll fareciod efficalIq
UP TO 200 AMPS
F UV UUP license Lid N— s 1.
6 W Dam �s Commcmr 201-11100 AMPS
F ti m ARCHITECTS DF.CLARATI ' SQ.CV tV T. OR AREA S/SQ.FT.
Z O m 1 understand my plans shall be used as public records. OVER 1000 AMPS
OZ q
�yFt�i SIGNS F.LECTRICAI.
Licensed Prnfesvioml ill...
(�
OWNER-BUILDER fr DECLARATION SPECIAL CIRCUIT/MISC.
W O L U 1 ngm as affirm that I an exempt from the Contractors Code:
License Law for the
613 a vf—i following reason.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
�Fy�1 0.a] which requires u permit to construct.alter,improve,demolish,or repair any structure
z,y}� prior to its issuance,also requires theuntil icau[for such Do file a signedstatement POWER DEVICES
CL quirespermit Le
W O char he is licensed pars Section
the pmvisioas of the Ce Business
License Law(Chapter
W o 9(commencing with Section 9000)of Division3of the Businwe and Pmfessione Cale) SWIMMING POOL ELECTRIC IgVALUATION
or that he isa.cromhewrom and the basis for dteslleged exemption.Any violation of UTLEIS.SWITCHES-FIXTURES �` O
F Z Q Section]03IS by any applicam fora pcmth subjects the applleam to a evil penehy o[
Sq not more than five hundred dollars($500). NLW RESIDENTIAL ELECTR 5 .Ff.
o E] L asowneroftheproperry,ormyemployeeswichwage mtheirsolecompensa[ion, Q STORIES TYPE CONSTRUCTION
a will do the work,and the structure isnot intendedorofferedforsale(Sm.9044,Business
and Professions Code:The Contractor's License Law does not apply to sn owner of
propertywbnbuildsorimproves thereon,undwhodoessuch work hlmselforthrough his
own ddNatsnchim t t r dedoroffered forsale.if, OCC.GROUP RES.UNITS
entp the have the burden
of mmemishat he id not build or improve for
purpose of
builder will have the burden of proving that he did not build or improve for puryose of
❑ las ownaonneproperty.amexomsryelycontracting wnnlicensed Nono-ad r QTY.. : " PLUMBING PERMIT, -FEE FLOOD zoNe APN
onnwal the project(Sec.7044,Business and Professions Code)The Contractor's
Liceree Law does not apply to an owteroTarearty who builds or improves thereon,and PERMITISSUANCE
who oontraat[or such proJeds with acoovacmr(e)Ilceneed pursuanno the Compactor's
License Law. _ ALTER-DRAIN&VE e ( /y - FEB SUMMARY- r. "
11lam exempt under Sw. ,B&PC for this reason BACK FLOW PROTF .DE OUTSIDEFEES
S i RECEIPT#
Y N
Owner Data
DRAINS-FLOOR,RO�F.AR ,C
WORKMAN COMPENSATION DECLARATION � / SCHOOL TAX YN
❑ Ihereby affirm that i have a certificate ofconsenfto scl6insme,or u artificateof FIXTURES-PER TRA DATE' ��> ECEIPI'#
Workers'Compensation Insurance or acertified copy rhereof(Sm.3800,Lab CJ which RK FF.F. N
covers allemployee's under,lik permit. GAS-EA.SYSTEM-1 UTLETS R\—
Cr
Policy# BUV61NAD&SlWq
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FF
❑ CeriGed a.,is hereby furnished. L
ig_ nifiad copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FG
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER/
COMPENSATION INSURANCE
(This adionaced not be completed ifthe permit is foram hundred dollars($100) SEWER-SANITARY-STORM EA.2WFT. ENERGY1E
orlesaJ
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECfR
not employ any person in any manner so es to became subject to the Workers PAID
Compensarion Laws of California, Date WATER SYSTEM/TREATING ere Rec m `
O Z Applicant
z7�-I iq
NOTICF.TOAPPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PUMP. SQ.FT. TOTAL:
F' to become subject to the Worker's Compensation provisions of the Labor Code,you must
ter ; fonhwidt comply with such provisions or this permit shall be deemed revoked. BUILDING Fe h
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE r
1 hereby affirm that them is a construction lending agency for the performance of rmTOTAL ELECTRIC FEE
l
O
he work far which this .it is issued(Sm.3099,Civ.CJ
Lki Lenders Name 'f' "
Larders Address QTY.e,- MBCHANICALPP.RMIT 'FEE PLUMBING PGE
L) 1 really that I have read this application end mete that the above information .'
L1a eaecr lugs nmomply with ellciry andcounty oN nances and smtelews relat gm PERMIT ISSUANCE MECHANICAL FEE
�^ gn budding construction,and hereby authorize representatives of[hismryroemer upon the lie,
CONSTRUCTION TAX
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
F7 (We)nam.to save.Indemnify and keep harmless the City of Cupertino against
liabilitiesgments,cos dexpenseswbwhmayinanyw.,mmue Ngam....id City AIR HANDLING UNIT(TO 10,000 CFM)
tie eoramp n[i this ermir.
AIR HANDLING UNIT(OVER Ift"CFM)
Ignam fAppheant nor Da EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dare Recei rN
ill the applicant or furore building occupant sore or handle haenrdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,9wtiw 25532(a)?
1:1 Yes 11 No VENTILATION FAN(SINGLE RHSID)
Will theapphcam orfalme buildingeacupant useequipmentardeviceswhich ami[
BOILER-COMP(3HP OR 100.0iBTU) ISSUANCE DATE
o hitan aus air examinations os defined by the Bay A.Air Quality Management BOILER-COMP(OVER 100,0011 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. M� A D
I have read the hazardous materials requirements under Chapter 6.95 of the
V�
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if Ne building does not currently have.cannot,char it is my responsihility to notify the gEp 48 f9
ccuat paof the requirements which must be in. to,to issuance of a Certificate of
Occupancy. i
Owner or amhorized agent Date TO ISSUED BY: f I
OFFTCS-