25209 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOinfidUtsm'irPIL's ll PERMIT NO. O
APPLICATION/PERMIT PLO'11 NG MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDENTIFICATION
B RLD^INGADDRFSS: SANITARYNO. APPLICATION SUBMITTAL DATE
1 V\ J ^O r- ✓ UNIT LOTp
4 ERS NA
RIfO,L CONTyOCOR'SNA LIC NO: NIC CONTROL#
ARCHHECIENGINEER: LIC NO: ADDRRVESS: ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MECfI
PERMIT ISSUANCE � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nmz Iherebywifrm Nal l am licensed under provisionsofChapter9hommencing with TOR DESCRIPTION
OOE- Section"100(11 of Division Jnf iM1e Business and Professions Coda and my license is in PANELS Val
muUrce full foand effect. \�4'T jYrsr
FZW License Class Lic.# UP TO 200 AMPS
w?y Dote Contractor 201-1000 AMPS
ZOyZ ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z_n I understand my plans shall be used as public records.
sn F; SIGNS ELECTRICAL
U IRN
Leered Professional
K OWNER-BUILDER DECLARATION SPECIAL CIT/MISC.
kOc'. I hereby affirm that I am exempt from the Contractor's License Law for the
m 01n following mason.(Section 7031.5,Businex,and Professions Code:Any city or county TEMP.METER OR POLE INST.
F� which requires a permit to consrroc6 alter,improve,demolish,or repair any structure
czi.Y7 prior to its issuance,also"itures the applicant for such permit to file a signed statement POWER DEVICES
,=<0 that be Is licensed pursuam to the provisions of the Contractor's Lireme law(Chapter
n.•Koa 9(commencing with Section]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC V ON
m_w or that he is exempt herefrom and rhe basis for the alleged exemption.Any violation of OUTLETSI-.Z> Section 7031.5 by any applicant for a permit mbjects the applicant to a civil penalty of SWITCHES-FIXTURES
=0 n •t van fve hundred dollars(S500).
�Cm .asownetoDhe propeny,mmy emplayecswim wages as lheirsolecompensufon. NEW RESIDENTIAL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
aw Idofhework.vdtMswcmreisnotinten.dedofoffercdforsale(Sec.7 4 ,Business
Pmfe,aiona Cade:The Commcmr's License[.so does nut apply to an owner of
pmpenywhobuilcisorimpmvesthemoq andwhodoce such work himulforshroughhis
ownemployms.provided that such improvememsar,not imendedoroffered forsals.If, OCC.GROUP RES.UNITS
however,the building of improvement is sold within one year of completion,the owner-
builder will have the burden of that he did not build or ins TOTAL:
proving prove for purpose of
❑ Las the project(See.704,am Business
and Profession,
Cmicensed Contractor's QTY' PLUMBING PERMIT FEE FLOOD ZONE ppry
oa rive the project(Sec.]1H4,Rusincea ane Professions Code:)The Contractor's
Licensntawdcersuchsnot apply toanith acnfproperrywhosedpulds mimpmdo,Contractors PERMIT ISSUANCE
who cammns forsucM1 pmjeas with a contractors)licensed pursuant m the Contracroh
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B P C for this reawn RACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY YN_
Owner Date DRAINS F,A ) RECEII'1'#
c WORKMAN COMPENSATION DECLARATION u - SCH YN_
❑ rni'Co affmmthmnhave e .,a verified
ed pop,
Lab C.)<le ofwhich
FIXTURES-PER TRAP RGCEII'f#
Workers Comparison Ter this eoracenified copy thereof(Sec.3gOD,Lab C.)which it .f Y_N
ars atlempinyce's under this permit GAS-EA.SYSTEM-1 INCA RTS RECEIPT#
Policy n
Company BU LDING DIVISION FEES
4(1?A
❑ Certified copy is hereby furnished. GAS-EA.SYSTEM-O ER
furnished. —_ PLANCHECK PEE
C3 Certified copy is filed with the city mipcmicndivision. CREASE/INUUSTRL TE INTERCEPTOR G
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS ME
INSURANCE
(This section need not4completed irrhe permit is foronc hundred Jollms($100) SEWER-SANITARY-STORM EA.200F1'. ENERGY PEE
or less.)
Icenify that in the performance.!the work for which this Permit is issued.[shall WATER HEATER W/VENT/ELECTR
not employ any person in any maturer,au as an become subject to the Workers PAID
Z Compensmionlawznfearfnmia. Date WATER SYSTEM/BEATING Date Raxiprp
Applicam
Z C) NOTICE TO APPLICANI':If,wor making this Cenifiwteof Exemption,you should NEW RESIDENTIAL PLM. SQ.BT. .
Fto becomcsubjceno she Wearies Compensation Provisions mi Lahr Code,you most TOTAL
fadhwith comply with such provisions or this pemut shall be,femoral revoked.
q# � BUILDING IEE
Z
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3(99,Civ.C.) TOTAL ELECTRIC ILE
Loader's Name
U.U Lender's Address QTY. MECIiANICAI,PERMIT FEE PLUMBING FEE
I cenify that I have read this applirw on and more that the above information is
connect.Iagree to comply wish all city and county ordinances and state laws relming to PERMIT ISSUANCE MECHANICAL FEE
F" building cunsuacrion.and herebyamhoneetepresenmtivesofrhiaciy to anteroom the
U Z above-memioned property for inspection pirpams. RVE�LAnOhaf
LTER OR r(STNGLERF�SID)
' ECIL CONSTRUCTION TAX
(Wa)agree to save,indemnify and keep hamdess the City of nst
liabilities,jidgmems,costs and expenses which may anon ayaccruity AIR HANDUNIT(TO 10.000 CFM)
in conuyucnre ol'she granting of tit' noir.
AIR HAND (OVER H),OX)CFM)
Signuwre of Ap ivanUConu ter EXHAUST UCI) CI 1.1 Ur GUrc i11
PAID
HALAR SMAgoccupSDISCLOSUREHEATING U ,000 BTU) Doct#Will the applicant nr!mute building occupant store or handle haalns definetl by the Cupcnina Municiwl Cade.Chapin 9.12,and the Hety HEATING UI W,OOp BTU) TOTAL:
Cade,Section 233J2(ap
CI yes 0N VENTILATIINGLE RESID)
BOILER-COMP JHP OR 100.000 BTU ISSUANCE
Will the applicant,lorfumte refined
by the
nBay Areisqu.Air Quality Ms agenne it ( )
hretrict? air conwminwts as defined by the Bay Area Ah Quality Mmagement BOILER-COMP
. DizWnP (OVER BTU)
11yes
�!
Ycs No NEW RESIDENTIAL#HCH. SQ.FT. �•
I have read the hassrdous mammals reyulremems undm Chapter 6.95 of she
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,shat it is my responsibility to notify the / � %�J
ccapent of me reyuirmnencm which must M mei poor m issuance of a Cenificvte of `f-`
occ uwney. ��/�'�/�'jI/���/
Owner or authorized agent Date TOTAL: ISSUED11lUt • 1