25159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEIERMIINO.
nuHmrvc DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
25159
BUILDING PROJECT,IDEN17N7CA'1'ION' -
BUILDING ADDRESS. SANITARY NO. APPLICATINSUB�ALDATE
. UNIT If LOT#
OW = AME: PHONE: / CONTRA OR'S NAME: LIC NO:
NIC CONTROL#
L
�A 'I' /HNGINEER: L NO: ADDRESS ,.
CONTACT: PHONE: 'ya+ ❑
@��+ ;s e. .,iBUILDINO PERMIT INFO
I^1d�s QTTYT. �BHL 'CTRIC�PERMIT FEH . ,
PERMIT ISSUANCE s IM
LDG ELECT PLO MECII
❑ ❑ ❑
Fit
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES -
p� affirm Z IM1ereby am(hell am licensed underprovieions ofChapmr9(cnmmencingwi[h -REST IAL I t TOB DESCRIPTION
(x100 Section 7000)of Division 3.f the Business and Professions Code,and my license is in PANELS t
F [EEF)1 full farce and effect. I
Fse Clvss RUPTO
Conacmr -1000 AL
MPS
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
O Z`"C 1 understand my pl...hall be used as public records.
sn SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC.
OyF I hereby from That I am exempt from the Contractor's License Law for me
m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METERORPOLEWST.
E"trJ ON; which requires it permit m concoct,alter,improve,demolish,or repair any structure -
V'— prior to its issuance,also malu ass the applicant formch permit to file a signed statemem POWER DEVICES
srl p0 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a (
9 mencin with Section of Division 3 of the Business and Professions Cade SWIMMING POOL ELECTRIC
0.0 tom gwi J VALUATION
XW❑y arthro he is 7031.5 by any refract and f the baspermit
ects the
exemption civiny l Penalty
of
GSection 703 L5 by any applicant forepermit subjects the appliranuoa civil penally of OOTLETS-SWITCHES-FIXTURES
onol more than five hundred dollars($500). NEW RESIDENTIAL ELECfR _SQ.FT.
❑ 1,mownerofthe Mro rty,ormyemployeeswiNwagesesiheirsolecompensation, STORIES TYPE CONSTRUCTION
will dome work,and the structure ismaintendedoroffered formle(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply m an owner of
propertywhoballdsorimproves thereamand who does such workhimselforthrom,hhis
ownemployees,providedthat such improvements orenotintendedoroffered forsale.If, OCC GROUP REFS.
however,the building m ariprovemenl is sold within oneyear of completion,the owner- 'TOTAL
builder will have the burden affirming that he did not build m improve for purpose of
s❑)Las owner ofthe err,amexclusivel tractor with licensed connucto t QTY'd,i-+ x PLUMBING PERMIT„A x �PBE` ' FLOOD ZONE ATN
property, Ycon contracting ;gy z. v ,�
consumer the project(Seo.7044,Business and Professions Code:)The Contracmrs
License Law doesnotepply manownertaTro,my whobuildsorimproves thereon,and PERMITISSUANCE
wharrntrneuforsuch projects with aconlrecmr(s)licensed pursavnrm the Coeracters AL'THR-DRAIN&VP.NT-WATER EA License Law. ( ) FEE SUMMARY .
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OU'T$IDL PEES
SANITARY Y N
Owner Date URAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers'Coyaffirmtan Insuanceorlificamof conumtrcof(ec.380,Lab C.)arle of
which FIXTURES-PER TRAP RECEIPT# '
Workers'Compensation Insurance or acertified copy themof(Sec.3A00,Lab CJ which PARK PEE Y- N
covers all employee's under this permit' GAS-HA.SYSTEM-1 INC.4 OUTLETS RECEIPT is
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy,is filed with the city inspection division. GREASEINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissecdon need no the completed ifthe Permit is form ehindi dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I certify that in the performance.fthe work for which this permit is issued,l shall WATER HEATER W/VE.NT/ELECTR
not employ any peman in any manner so as to become subject to the WorkersPAID
Compensation Lawsof Califomie. Date WATER SYSTEMITREATING
Applicant Dore Receipt#
O z
z7�-I 0 NOTICE TO APPLICANT.If,after sanding this Certificates of Exemption,You should NEW RESIDENTIAL TIME. SQ.FT. TOTAL:
H rq became subject in the Workers Compensation provisions of the Labor Code,you moat
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
^a 1 hereby affirm that there is a construction lending agency for the performance of
V C) the work for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC HE
w U Lenders Name F+ i T,t'k T$ t
F-t Leaders Address Q ire P
eMOCHANICAL f3RMIT s:.SEE
himPLUMBING HE
L) I,re"ifyagree
that 1 have read alts city
and county
and ndin that the above laws
information is '
a correct Iogreamwmpld with
yntyand coonryntativsofthidciaminwerrefiningupom PERMIT ISSUANCE MECHANICAL PF.E
immenmentioconstmefiogant herinspechoizpurpses.representatives cirymemer upon the
L) z above-mentioned pmpeny for inspection purposes. ALTER OR ADU TO MF,CH. CONSTRUCTION TAX
°-� (We)agree to save,indemnify end keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may inany evayacerueagalnslsoid City AIR HANDLING UNIT TO BLOW CFM)
in consequence ofthe granting of this Permit.
AIR HANDLING UNIT(OVER I0,000 CPM)
Signature of Applicant/Coalmalm Date EXHAUST HOOD(W/DUCT)
PAID 6.T93 74 0[
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dem Receipt Ir
Will the applicant or future building occupant store or handle hazardous materialO
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) 'TOTAL: D 1
Cade,Section 25532(a)7
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,000 BTU) P w IJS6NCE DATE
Will lair rioieanlorrpwm building by the ay equipment unlit c Management tl� M
hazardous air conmminams as defined by the Bay Area Air Quality Management District'. ROILF.R-COMP(OVER 100,000 BTU)
all
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 1(193
1 have reaA the hazardous materials requirements under Chapter
N
r 6.95 of the J3
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that Ur UUF'tH (�/' U
if the building does not currently have a moral,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a C nifirm,of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: