25360 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPFRTINO BUILDING-1,1A. RI AI' PERMUNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /1 /�O
BUILDING PROJECT IDENTIFICATION L FVC
BUIILLYD��INkI1G 1A 1DDRESS: SANITARY NO. APPLCSA'I[ON SUBMI'I']'AL DATE
V+4 ( �,�, I ' L�/-� UNIT# LO'I'M
OWN SN M PHONE: C CI(yfSN ME: I O:
N/C CONTROL N
tCtil lTiCT/ENGINEER: LIC NO: ADD SS: �I ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Matz lhcmbyuffrmthull aorlicemsedmcerpr..toe.Choper9(commencingwith JOB DESCIPI'ION
p B
00 Scene. Division Sof the minessand Professions Code,and my license is in PANELS
FFaVE fall fo vandeffect UP T'O 2(111AMP5
pa-,Z W License Clas Lie#
m?y Date Contractor 201.IWOAMPS
ZOvz ARC]IITECr'S DECLARATION OVER IM)AMPS
SQ-Fr FLOOR AREA S/SQ.Mr.
Hai—
pp I understand my plans shell heated!m public records.
C^N�; - SIGNS ELECTRICAL
CYY - Licensed Pmfesxional
It' V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ipaxT I hereby affirm that]am exempt from the Contractor's License Low for the
W 3 a y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
,o'! which requires it remark to construct,offer,improve,demolish,or repair any structure
,!(>� priurto its issuance,also mluire,the applicant Tmsuch permit to rile a signed statement POWER DEVICES u V ® w,
a uV ( \ 'V
Q0 thatcommscnsedpursuann7000)of Division
the Ce Business and Professions
ode) SWIMMING POOL ELECTRIC
Lcd�C 9(commencing hisexempt
Suborn and he India
tal the Business and .Any vote Cod e) ® M r,-.� U 3f�
W=m or 7031. by
say applicant
the bmisforbeasegedeaempti to civil violation of OUTLETS-SWITCHES-FIXTURES uV V_J I[L� 1Ra{a
i Section 7031.5 by any applicant fora permit subjects the applicant to o civil penalty of
0on m1, town roftheve m dollars($500). NEW RFSIDENTIALELCCFR _SQ.FT.
e'' $ ❑ .dou mernDhepropent',ormycmpendedmithwedfortark,(sole compcnsiiess ATE STORIES $TRU 'TION
L willPante:work.Cde:The Clureianatl Licensor mothered not (Sec
to an owner of
ono Pny wh ons Code:The Contractors License Law Poco s such or apply lf rt owner of
nonenywyess,pdsorimpravcsthereparave whaon,mminende moffieedthrough his
own emplmycea,pmviori ohm wchimnmvld within
firriatheo e. r- OCC.GROUT' RES.UNITS
however,the building or improvement is sold within oneynar or improve
omm a for the owner- TOTAL:
builder will have the harden of proving that he Pio not buil)or imnrove for purpose of
ateJ.
❑ Los the pr ject(Sec.704am acre ivclycommcnimms Ca c:)n cnmucmrsta QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.oarro ncrof,s and Pwho build t orme The Com'clan'and PHRMIT ISSUANCE
LicenceLaw does notapplyct anowner mproperty lihabuiWsrs improves thereon,and
whence Low.for such projemswith n<nntruaor(s)licensed Pursuummthn Contractor's ALTER-DRAIN&VENT-WATER PA
License Lew. 1 > PF.E SUMMARY
❑ 1 and exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT'.DEV ICF. UT, :.S
SANITARY Y N
Owner Dale DRAINS-FLOOR.ROOF,AREA,GOND. Drill'.
WORKMAN COMPENSATIONIA
DHCIIATION SCHOOLTAX YN
I hcmbyaff,.that l havcacedificaleofernem to self-insure,can cerfificdomf FIXTURES-PER TRAP RECEIP`L#
taken,conipmead...Insurance art nnertifeA cnpY ohereof(Sec.3500,Lab CJwhich PARK FLEE Y N
n all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RCCEIPI'#
Policy# BUILDING DIVISION THIS
rCray GAS-EA.SYSTEM-OVER HE
4 A) PLANCHECK FEE
eni6ed copy is hereby furnished.
wLed copy is filed with the city inspection divisinm GRFASE/INDUST'RL WASTE INTERCEPTOR GRADING FEE
Clial IIICATE OF EXEMPTION FROM WORKERS' GRHASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section neodn'he completed ifthe permit is for one hundred dollars($Into) SEWER-SANITARY-STORM EA.20(IFT. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENT/CLECTR
not employ any person in any manner so as to become subject to the Workers PAID
Ccroadminnl.awsof Celifomia. Date WATER SYSTEMJTREAI'INC Dam Receipt#
O z Applicant
zNO LICUTO APPLICANT:I F.after ranking this Certificate of Exemption,you should NEW RES IDENT]ALPLMB. SQ.FT. TOTAL:
F' .. become subject to Ne Workers Compensation provisions of the Labor Code,you must
C4 , forthwith comply with such Provisions.,,his permit shall be deemed evoked. BUILDING FEE
a5 CONSTRUCTION LENDING AGENCY SEISMIC FEB.
Vz Ihereby elfin that thahere is a construction lending agency for the predominance of
O the work for which this permit is issued(Sec.3097.Civ.C.) TO'PAI.: P.LECIRIC FEE
W P Isnddea Name -
Lender's Address - QTY. - MECHANICAL PERMIT,;p PEE PLUMBING FLEE
W I certify that I have read this application and dote that Ne above information is
T' 9L correct.]agree to comply with all city and county ordinances and some laws efalingt,, I PERMIT ISSUANCE MECHANICALF)i
VE-' ,,0 building construction.and hereby authorise repeun'oiveeaftbiscity mender upon the CONSTRUCTION TAX
above-mentlnned property for inspection purposes. ALTER OR ADD TO MCCH.
(We)agree to save,indemnify and keep humorless the City of Cupertino against
liahililies,judgmems,s, aadexpe . yinanyw c e' sui By AIR HANDLING UNIT IO,000 CFM)
of than;'mid,of t
`µms AIR HANDLING UNIT(OVER I FLOW CFM) .
.Tgrand.of Ap,licanUCommctor Dale EXIIAUS'lFOOD(W/DUCTi
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,1100 BTU) Date Receipt#
Will the applicant or future building occupant store or handle ha'rdous material
its def ned by the Cuperin0 Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0010 BTU) TOT
Code,Section$532(¢)?
11 Yes CI No VENTILATION PAN(SINGLE RESID)
Will theappllcmttorfuturebuildingr:ccumat use tardeviceswhich BOILER-COME yHP OR 10f,"BTU) AT
'U) ISSUANCEDE
equipmrn emit
,hosannas air camuminan,as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
ismet'!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the haevdous materials requimmems under Chapler 6.95 of the P q ' D
California I health&Safety Code,Sections 25505,25533 and 25534. I understand OA
m
if the building does not=en0y have a tenant,trial it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
Owmernr amborieed agent Dole - ISSUE
OFFICE Ivy