25561 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
rRICAL PERMITNO. 25561
CITY OF CUPF.SION PLUMBING-MF,CI N'l IFIC
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROIBCT IDh:Y1'IPICATI(IN
BUILDING ADDRESS:
�`•�`a .a,./�'p� SANITARY NO. A/PPPUCATION SUBMITTAL DATE
Mb V, {m am UNIT# LOT# Cf.—I /co
OWNF S AME: �L �PHO�P{_\ CO RACf 'S ME: LIC NO: l � �J
N/C CONTROL
RCHI-I'ECI'/ EER: LIC NO: ADDRESS:
CONTACT: PHONE: QTY. ELECTRIC PERMIT �V FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB NEED
PERMIT ISSUANCE ❑ ❑ Il{L
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION T
Dy.Z Ihereby affirm that l son licensed underpravisionsol'Chapter9(commencingwith
04L) Senion]00tef Division3oF theBninesn and Prof v ele,end mylianx ism PANELS
FUK
full force and R«t.
C c. UP TO 200 AMPS
6 License Lip
in y Data Contractor 201-1000 AMPS SQ.FT,FLOOR AREA SISQ.FT.
ZOyzis ACHITECT'S DECLARATION OVER IOW AMPS
pp I understand my plans shall be used as public records.
ro, u1 I SIGNS ELECTRICAL 1
Q f,� Liamcd Professional EK WOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
" I hereby iffvm that I am exempt from the C.a.cura License Law for Ne D IN
¢ following reason.(Saban 7031.5,Business and Profession Code:Any city or county 'TEMP.METER OR POLE INST.
Fe�OJ which requires a permit to construct,alms,improve,demolish,or minor arty structureMPUTER
2s°}� priormitsissuunre,also requires the applicant forsuch parasitic,file stagnant summers POWER DEVICES
y�j a p that he is liccnd pursuant to tM provision of the C m es License Lew(CTapmr
y ACSWIMMING POOL ELECTRIC
oW 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) E
'
to or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIX'1'IIRFS
Y Section 7031.5 by any applicant for a permit subjects the applicant m a civil pantry of
not mom than five hundred dollars C$5000
KK ❑ Lasownerofthepropeny,ormyemploy«swithwage utheirsoleco Per u.on. NEWRESIDENTIALELECfR —SQ.FI'. STORIES TYPF.CONSTRUCTION
y3� will dothe work,endthe svactureis not imndedoroffertd for We(Sm 7044,11minens
and Professions Code:The Communes License Law,does not apply to an owner of
propenywhobuildsorimpravestherean.and whoduss such workhmaelforthroughhisWC GROUP RES.UNITS
ow ever,tyees,p building,
improvement
pr vemenpnve within one
intenddmalfcred diorama,
iosIf,
however,the have
the
b improvement is sold within one yen or improve
omm a for thea se,of TOTAL
builder will have the burden of proving that he did not build or improve for purpose of
We.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
ElI,asownerofthepmpeny,umeaclusivelyconimctingwiNlicenedconVacuuu
musician the prof«t(Sec.7044,Business and Professions Cade:)The Cenmcmr's „
License LawdmsnotaMlymanowncrofMMnywhobuildsorimpmvathereon.end PERMIT ISSUANCE
whormrects for such projects with a commands)licensed pursuant to the Contractor's ALTER-GRAIN&VENT-WATER(EA) F'EE•SUMMARY
License Law.
❑ I am exempt under Sec. B&P C for this moon BACK FLOW PROTECT.DEVICE O SID EES
SANITARY Y N
Owner Dat° DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I herebyiffrm that l have a milificare ofconxnuo self-insure,or a cerificem of FlXTURCS-EBR TRAP RECEIPT#
Warkers'Campensaom ins.ma certified copy,dmm(Sec.Jg00,Lab C.)which PARK FEB - Y N
Covers all employees under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS ftDIVISIOM
Palic # BUILDING DIVISION FEES
nY GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEB
mired copy is hereby funishM.
Certified copy is Ned with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPDON FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(This sectionnad notbecampletd lithe pamdt is far one hundrddollers(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
carless.)
Icenifythasintheperformsnceoftheworkforwhich Wspenrdsisiasud,lshall WATER HEATER W/VENT/ELECTR
not employ any person to any manna so u to become subject to the Workers' PAID
Compensationlxwsof Califomla. Data WATER SYSTEM/IREATING Date Receipt#
O z Applicant
O NOTICE TO APPLICANT:Lf,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PP. TOTAL:
[~/3 become subject to the Worker's Compensation provisions ofthe Labor Code,you must
forthwith comply with such Provision or this#antis shell be d«mel nw kd. BUILDING IEE
RWi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affint that there is a construction lending agency for the perfonu nce of
5 z TOTAL: ELECTRIC ME
V O dm work for which this permit is issued(Sa.3097,Civ.CJ
Lender's Name PLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
W1 certify that 1 have red this application and state that she above indovnmion is MECHANICAL ME
comms. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building connection,an authorize repreV,[. ,Yha
of this cirymermrupon the CONSTRUCTION TAX
L) 2 above memimd pro yf inspc ".a purposALTER OR ADD TO MECH.
(We)ago to emnity anJ ka City f Cupertino agulnnliabilities,jud a edea way«ceeagshost. City AIR HANDLING UNIT(TO 10,000 CFM)
mom qts ting pew t.
AIR HANDLING UNIT(OVER 10,000CFM)
ignu APP monUCom r Dam EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TOIW,"—'TO) Date Receipt#
Will the applicant or future building occupant storm or handle hazardous material HEATING UNIT(OVER I(I),000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sudety r7JE
Code,Section 25532(x)? VENTILATION FAN(SINGLE RPSID) —_
❑Yes ❑No
JMISVANCE DATE
Willtheapplicanmrfuturt buildingoccupermsecquiptmntordevicn whichcmit BOILER-COME CHIP OR I00,000 BTU) {i
ezardous air contaminants as defined by the Bay AAir Quality Management BOILER-COME(OVER 100,000 BTU) �J
Direa strict? El9.Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. SEP d 7
1993
I have read the harnrdom roamdals requirements under Chapter 6.95 of the
Celifmnia H.Ilh&Safny Cde.Sections 25505,25533 end 25534.l understd N
anat CITY Uh CurcK l u
if the building does not currently have o lenam,that it is my respunsibiliry to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of 1111�`�` Fp����pp����s//��
Occupancy.
Owner m aeboreed agent Data ISSUED BY:
OFFICE