25331 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHANICAL PERMIT NO. 25331
.
BUILDING DIVISION APPLICATION/PERMIT
' BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: pp SANITARY NO. APPLICATION SUBMITTAL DA'IT
///I t V� UNIT# LOT# 6
4R AM
OWNERS E: PHONE: CONT 'S A LIC NO:
(J N/C CONTROL#
ARCHITF. /ENGIN R: LICNO: ADDRESS:
CONFACT: PHONE: q
FFr *BUILDING PERMIT INFO
Q7'1' s,%.tr ,�ELECTR,[§C.PERMIT„,. rB a g
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE / El ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
oxz I lumebyaffirm that l am licensed underprovisionsofLTapter9(Commencing with _
100 Section 900()af Division 3 ofthe Business and Professions Cadet and my license is in PANELS /s
full force and effect. J
License Class Lic.# IIP TO 200 AMPS
so 1 Dam Connote 201-1000 AMPS
F,z ARCHITECTS DECLARATION SQ.Ff.FL
OOR ARG $/SQ.FT.
Cz O m— I understand my plans shall be used as public records. OVER 1000 AMPS
O Z—M SIGNS ELECTRICAL I�
QLicensed Professional A E
6
OWNER-BUILDER from
mFLGRATIGN SPECIAL CIRCUIT/MISC.
cul d 1 hereby affirm that I um exempt from the Commemrs License Law for the 0
W 3 C,m fol owing inusoa.(Section 9031.5,Business and Professions Cede:Any city m county TEMP.METER OR POLE INST. p V,p
f•]' O4 which requires a permit[c construe,super,improve,demolish,or repair any machine WYn prior to its issuance,also requires the applicant forsuch permit m file asitime statement POWER DEVICES E
C 4 p that he is licensed pursuant m the provisions of the Contmemfs Lleeneelwx(Cheptu L
�y. SWIMMING POOL ELECTRIC
9(Commencing with Section of Division 3 of Business and Professloos Code)
j_^or, or he is exempt therefmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-PIXTIIRES
i Section903L5byanyapplicantfora permitsubjects the applicant to a civil Penalty of
pet than five hundred dollars(g5W).
Q NEW RESIDENTLV.ELECTR 5 .FT.
eC m I snwnerofthepropmy,ormyemployeeswithwagesastheirsolecompensafion, Q STORIES TYPE CONSTRUCTION
q Rothe work,and the structure isnm mandederoffimad Forsale(See.9044,Business
d Professions Code:The Contractor's License Law dces not apply to en owner of
roperty who but Ids or improves thereon,and who does such work himselfor through his OCC.GROUP RES.UNITS
tun employees,provided that such improvements we not intended or offered foreale.If,
however,the buildtngorimprovement is sold within one year ofcompletion,theowner- TO
builder will have the burden mproving that he did not build or improve for purpose of
Eley n 4u
E3 1,as owner mfthe propeny,con ContractingexclusivelyContracting with licensed contractors QTrY�
to PLUMII7NG PERMIT'u FEE` FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions Code:) ra CmUriamrs ~
License Law diesnotapply toanuva.,. im act,whobuildsmimper ,esthereon.and PERMIT ISSUANCE
who contracts forsuch projects with seentraculds)Iicensedpursoant[cthe Controcntts
Lleense taw. ALTER DRAIN&VENT-WATER(EA) ==FOE SUMMARY
mxe
-
❑ I uempt under Sec. ,B&PC for this reason PACK FLOW PROTECT.DEVICEYOUTSIDE E
SANITARY Y N
Owner Dam pRAINS-FLOORROOF. COND. RECEIPT#
, ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affinn[hetlheveawrtifiema ofamsenuo selFVosuro,oracertificateof FIXTURES-PER TRAP RECEIPT Is
WorkersCompensation lmuranceor a candied copy thereef(Sec.3800.Lab C.)which PARK FEE Y N
carousal]employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy - BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(G) PLANCHECK PEE
❑ Cenilied copy is hereby Famished.
❑ Certified copy is Filed with the city inspection division. GRGSE/INDUSTRL WASTE INTERCEPTOR GRADING WE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need out be completed if the permit is far one hundred dollars(S 100) SEWER-SANITARY-STORM EA.201 ENERGYFEE
ter less.)
I certify that in the performanceoflhe work for which this permit is Tart 10.11 WATER 11 PIER W/VENT/FLECTR
not employ any Person in any assume so as to become subject to the Workers' PAID
Compensmtoo laws of Ciffomia. Date - WATER SYSTEM/I'REATING Data Receipt#
O z Applicant
C NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT, TOTAL:
On become subject to the Worker's Compensation provisions of the Labor Code,you must
�. forthwith comply with such provisions or permit shall be deemed invoked. BUILDING FEE
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency For the performance of
the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC PEE
Lender s Name r,c F r n v x c ror
U Leaders Address QTY$_ % MECHANICAL PSRMIT x ;s PCE„j; PLUMBING PEE
1 cemly that I have read this application and were that the move information '
cored.I agree to comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE MECHANICAL FEE
F'0 building construction,and hereby sehonzc representatives ofthis city[center upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree[c savq indemnify and keep harnlcss the City of Cupertino agalmst
liabilities,judgments,costs and expenses which may inany wayaceme againstsaid City AIR HANDLING UNIT(M IB,UOB CPM)
o seq. a of the granting Of this it.
-71 AIR HANDLING UNIT(OVER IQOOO CFM)
gnathre of Arlican rector ere EXHAUST HOOD CNMUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10A000 BTU) Dam Receipt It
Wil l the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER IOO,000 BTU) T AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)1
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the applicanmrfuture bmildingoccupantuseequipmenmrdeviceswhich emit
BOILER-COMP UIIP OR 100,000 BTU)
�harardous air connotations as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,000 BTU)
Distnet7
PAID
ElP A 1 D
Yea ❑No NEW RESIDENTIAL MECH. SQ.Ff.
I have read the hazardous materials requirements under Chapter 6.95 of the ��e
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that `
Af the building does not currently have.tenant,that it is my responsibility to nmi(y the ^
occupant of the requirements which must bo met prier to issuance of a Certificate of HI t�'V a tt.
Occupancy. tnfV
Owner m uwhlrimci agent Date q'OTAL: ISSUED BY: