25901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mm.lusui-ecP.rramaL rr:RMITNo.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL n [�(]O
BUILDING PRO JE(II'IDENTIFICATION L J J
BUILDING ADDRESS:. ' SANI'T'ARY NO. AION SU/Rmri At.DATE.
UNIT# LOT# �.Y
OWNS SN ME: PHONE: CONTRACIOR'SNAME: LICNO: l
\ a NIC CONTROL#
ARCHITECTIENGINE LIC NO: ADD S: a El
CONTACT: PHONE: aIC PERMIT FEE
QTY. ELECT BUILDING PERMIT INFO
-
4.0 BLDG E ECf PIX MF.CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION pPPLIANCCS-RESIDENTIAL
El
Op.Z I hereby affirm that l am licemed unJerprovisionsofChapier9(commmeingwith' JOB DESCRIPTION
(100 Section 7")of Division 3 ofthe Business and Professions Cole,and my license is in PANELS
C W F+ fill force trod off ��.�.
QFZW Date Cls ContrI.ol
UP 002 AMPS
m to 7,
Date CCTSDr OVER
1000 AMPS
F ARCHITIiCTS DECLARATION F100RVA $ISQ.FT.
0O vii OVIiR 10n0 AMPS
1 Jertund my plans shall be used m public records.
j�y j SIGNS ELECTRICAL
QLit :eJ lhn ss
Kp, Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
px.OaU 1 hereby affirm That I vee exempt from the Contractors License Law for the
u131s��Gn which re,marmn.(Scnt 1.construct,
end Professionsh,or An,
cityorcounty e TBMP.METER OR POLE INET.
FFe2 J which requires a permit to conawn,alter,improve,demolish,or mpur any awnum
CW}� prior to its issuance,also mluims the applicant(orsuch permit mfile asignee statement POWE0.DEVICES
11K�0z n
Thal he is licensed pursuant the provisions ofthe Contractor's License Law(Chapter
I1geLL 9(commencing with Seetion7000)of Division 3 ofthe Business and ProfessSWIMMING POOL ELECTRIC ions Cede) VALUATION
Sethat ction 731.5bpu, plimmf the M1a.itsbjthe alleged eaemptinn.Anyviolationof UTLeTs-SWITCHES-FIXTURES
�SZ,Q Section 7031.5 by anyapdd.1l far.rs($5 unit subjects the applicant to a civil penalty of
d mm ore than five hunrcJ Aallan(E$00). Q. STORIES TYPE CONSTRUCTION
d O NEW RESIDBN'11AL ELBCfR S FT.
Wm ❑ Lmnwnendthe prnpeny.nrmycmpinyceswithweges ustheirsolemmpensednn,
d will doresions mdeh he Contrast
otLicense Law does not
to not Business
and Professions CMe:The Co es therears License Lew doh not apply tort owner of
ownpoulemury whces.prsmimphat suchimpowndwhoamnotiuendedoes such rofficor firoughhi. OCC.GROUP RES.UNITS
own cmployees.providW thauuchimpmvemenuert nmimende-0oroffered forsala If,
however,the building or improvement is sold within ane year of ecmpletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE FT.00D 2oNE ApN
❑ I,ct the profrepropety,am Business old Pr mdiions C de:)'Me Cuactorsto
License the project(SOC.7catoro ousinesr and Professions Code:) Contractors
License Law does not applymmownaofproperry whobuilds orimproves therwn,and PERMIT ISSUANCE
whocnatmnpforsuch projects with ucontramods)licensed pursuant o the Contractor's nAI:MR.DRAIN at VENT-WATER(EA) FEESUMMARY
Lice wLaw.
❑ I ant escmpt under Sec. ,B P C far This reason BACK FLOW PROTECT.DEVICE O SID E F
- SANITARY Y N
OwnerDam RECEI I'T#
ND
WORKMAN COMPENSATIONDRAINS-FltDECLARATION RNA
SCHOOL TAX Y N
❑ I hereby affirm that l have a cerificam nsem ofcoto self-insure,or a certificate of t _ RECEIPT
Wmkttz'Compenmtion Insurance onccenified copy chorea((Sm.3B00,Lab CJ I;IXTURES-PER TRAP l which !-. -- PARK FEE Y N
covers all employees under this permit. REM, #
GAS-EA. STR111:I�INCg4 f S BUILDING DIV ION PEES
PoI'Icy#
Compmy GAS-EA.SYSTHM-OVER 4(EA) PI!ANCHECK FEE
❑ Certificdcopyisherehyfumished.
❑ CenilieJ copy is filyd with the city inspeeuon division.
GRE TAS
UURTRI.WAS _.Qi6DINGFEC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thismetiom need not be,completed ifthe pemtit is Tanana handled eollan($IN) SEWER-SANITARY-STORM EA.200FT. ENIiRGYP
a IcaIJ
Icety that itho n in
nommr so work for which suPermitjeco issu Worlmali WATER IICATF.R W/VF.NT/tiLIiCfR
not employ any person in any manna so m to become subject to the Wohen' PAID
Cnmpansntion Laws of California. Dote 'WATER SYSTEM/fREA'fING Receipt#
O Z Applicant
zO NOTICE TO APPLICANT:If,after making this Cmificemof Exemption,you should NEW RFSIDENTIALPLMR. SQ,Ff. TOTAL:
(A become subject to the Workers Compensation provisions of the Labor Code.you most
R fonhwith comply with such provisions or this Permit shall be deemed revoked. BUILDING PER D
4E1 -
Q. []
CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm rat rem is a construction lending agency for the pednrmmce of
U O the work for which this permit is issued(Ser.3097,Civ.C) - TOTAL: Ii1.liCTRIC FE
Lender's Name
LL' Lcneers Address QTY. MECHANICAL PERMIT FEE PLUMBING Mo'
W Icenify rot 1 have read this uppliation vnJ stem
that the aMvc information is MECHANICAL.hC:
correct.lagmetocomplywiUOdIchymdcoun lyordinancesandswmlawsrelatingto PERMIT ISSUANCE
F' builaingcnnslmction,mdhenhyauthtrizercpMenmtivuofthiscityloenmruponthe CONSTRUCf10N'fA
U above-menJoned property for inspection purposes. AIAEROR ADD TOMECIL - tel.
(We)agree to save,indemnify and keep harmless me City of Cupmino egvimt
liabilities,judgments,costs and expenses which may in any way Income against said City AIR HANDLING UNIT G 010,00I CFM)
in mseyuenec of the gmatial of this permit. -
��" AIR HANDLING UNIT(OVER I0,(g10 CPM)
Signawreo MComrecvn D e EXIIAUSTII00D(W/DUCT) - PAID
HAZARDOUS MATERIALS DISCLOSURE
" HFiATING UNIT(TO IN."BTU) Dote Rue t If
Will the applicant or future building necapmt store or handle hnaeNous material I MATING UNIT(OVER IN."BTU) T TAL
as JefinM by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safely
Cn le.Section 25532(a)7
❑Yes ❑No VI?N'I'ILA'I'ION FANN(SINCLP.RI:SID)
Will the applicanmrlinurehuilJinguavpam use eyuipmemnNeviceswbich emit
BOILER-COMP(3HP OR IWO)O RTU) ISSUANCE DAT
hmaNms air ecomadna.Is as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I D.W0 BTU)
Model'
Model'
❑Ycs ❑No NIiW RESIDF.NTIAI.MGCII. SQ.IT.
I have read the hood..,materials requirements under Chapter 6.95 of the FEB 1 5 14
California Ilmhh&Safety Code,Sections 25505,25533 and 25534. 1 understand that s .7C
if the building does not currently have a tenant,that it is my responsibility to notify thev
Oanpant of the reyunmiants which must he met prior to issuance ma Certifiale of al I Ul-
ccupmcy. - a MI
Owner or uulhorizcd agemt - Date To ISSUED BY:
OFFICE