25547APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOr' A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING . MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
25547.
0 ING`ADDRM..
SANITARY NO.
APPLICATION SUBMITTAL DATE
O / Ut ji., UNIT# LOTH
l
OWNERS E: PHONE:
Y
CONTCfO"NAME: r E LIC NO:
(9 `It
N/C
❑
CONTROL#
CHITF. GINE ER: 1
ADD 5
tw
CONTACT: PHONEr
QTY.*ELET@ICtPERMIT FEE
`ERM s: e r..,,
BUILDING PERMIT INFO
BLDG PLUMB MECH
ISL
PERMR ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I facom affirm Natlam llcensedunderprovisions of Chaptm9(commmortagwish
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Section700E.f Division 3ofrhe Business and Professions Coda and my license is in
e and effect.
PANELS
Lk
License 6sD Lin.w s9 q,�`
Duce Contractor T G
UP T0200AMPS
201 -1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ. FT.
SIGNS ELECTRICAL
Licensed ProfesslonN
SPECIAL CIRCUR/MISC.
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 .m exempt from the Ceraccrors License Law, for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
�•"
® S e
TEMP. METER OR POLE INST.•`
•
which requires a permit to construct, nicer, improve, demolish, or repair any structure
o
,nanoit. kmance,ulsorequires theapplicrun Ea®chrnedatem
penitto file. sigstent
is licensed pursuant to the provisions ofthe Convuctor's License Law (Chapter
of Division 3 ofthe Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
Section 7031.5 by any applicant for a permit subjects them, a civil penalty of
POWER DEVICES
Tthathe
,,, F—_
%
L� [3
�MNSTRUCTION
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
nor more than five hundred dollars ($510).
❑ 1,asownerofthepmpTty,ormyempinyees with wagesastheirsolecompensation,
1
STORIES
NEW RESIDENTIALELECTR _SQ.
apply. yoan, Boniness
will dmhe work,C dthe he Connector's
Code: The LicenseLae does not
enrmemr's License Law does nor apply to an owner of
and Professionsbuilds
r
mangroves
propenyle,er, ldosidedal suchereon,amdwhodoessuchwmk himfewdthrough his
own employees,provided Thorsuch improvementsinE no,yearoedoroffered
OCC. GROUP
or improvement is sold within one year of thea nIf,
theoweer-
however, @e bunhave
the
have the burden of proving that he did not build or improve for purpose of
improve for
QTY. PLUMBING PERMIT FEE
m1c.),rwill
ale.).
❑ Las with licensed
FLOOD ZONE
EA
the prtect(See.704am Business
the project (Sec. and Professions Contractor's
Code:) The Cmpon,
apo,
License oanopl, nwrofes aria
whabrill Nereon,and
LicenseLaw dfrsuch pplytoamwnerofproperty whosed
PERMITISSUANCE
who contracts for such projects with econracror(s)li<ensed pursuant to the GonwQmr6
pursuant to the
License Law.
ALTER
FEE SUMMARY
❑ 1 am exempt under gee. , B & P C for [his reason
B CK FLOW PROTECT. DEVICE
OUTSIDE! EES
Owner Date
DRAINg- FLOORROOF, COND.
. ,, .
SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARATION
' ❑ Thereby affirm marl huveecertificnte of emnsem to self -insure, ors cerrifcare of
Workwa'Compen6mtion lrlsumnce oracenified Dopy thereof (Sm.3800, Leb CJ which
SCHOOLTAX YN
RECEIPT#
FlXTURPS- PER'TRAP
PARK ME Y N
covers all employee's under this permit.
Policy #
GAS - EA. SYSTEM- INC. OUTLETS
RECEIPT #
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Certifedcopyisherehyfumished.
GREASFpNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CEnifrdeopy is filed with theeity inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA, 20AFT.
ENERGY FEE
(This section need notbecompleted ifthe permit is foranehundred dollars ($10h)
or less.)
WATER HEATER W/VE.NT(E,LECfR
I cenify dentin the perfonnanceofthe work far which this permit I.rsmed, I shall
not employ any person in any manner so az to become subject to the Workers
PAID
Cminpam ilioml-awsof Califomia. Data
Applicant
WATER SYSTEMITREATING
Data Receipt#
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject o rhe Workers Compensation provisions of the Labor Cade, you must
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
TOTAL:
ELECTRIC FEE '
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
QTY. MECHANICAL PERMIT FER
PLUMBING FEE
I cenify that I have read this application and stare that rhe above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby nothom ereplesame fives of chiscity to morm sen the
above-mentioned property for inspection purposes.
abopose
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupenino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in consequenoeo a mnWg it.
—/�.
AIR HANDLING UNIT (OVER 10,000 CFM)
gnamor Apdicom/Cmmpwt., Date
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO UXLW.BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the the Cupertino
orf r. Municipal Code, Chat store or hanand the Health and oarmil
as defined by the Cupenino Municipnl Coda Chapter 9.12, and the Health and Safety
Safety
HEATING UNIT (OVER 100,0!01 BTU)
DTAL:
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)'
El Yes ❑ No
Willthenpplieantnrfumrebullding occuWmmseequipmemordevicee which emir
BOILER -COMP (341P OR 100,000 BTU)
ISSUANCE DATE
hamrdous air contaminants as defined by the Bay Area Air Quality Management
District'
BOILER - COMP(OVER 100,0fiO BTU)
❑ Yes ❑ No
PAID
NEW RESIDENTIAL MECH.—SQ. Fp.
I have read the hnrordoun materials requirements under Chapter 6.95 of the
that
California theeria Health not ently Codehaveans 25505, 5is and 25534. 1l un mstand notify the
ng do & Safety Code, Sections 25505, t itis end 25534. 1 understand that
iftebuilding
,as�
"{F�/`_;/(7"� 93
occupant of the roqulremenrs which must he met prior tdissuanw of a Certificate of
tlO�Ma
Ocemancy.
ISSUED B Ct1I INU
Owner or amhodmd alter,
TOTAL:
OFFICE