25527 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOJYJNli-ELLUMI A. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25527
BUILDING PROJECT IDENI IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBsTiTAL DATE.
vL- N , IAT#
O QRS NAM& �� YH NE: / —co T"ACI RS NAM& LIC NO: N/C CONTROL•N/
!q C�-9-G..✓.� S— /fib
•ARCHITF.LT/ENGINF.ER: LIC NO: ADDRESS:
ni
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p y�y Ihercby affirmthat l am licensed underprovislons of Chaprer9(commencing with
Xp�1,00 Sectout 700ID of Division 3 ofthe Business and Pmfessions Code,surest my license is in PANELS
FZyp License Class Lic.g UP T0200AMP5I.=V6-
yr<a- Date Cmdrocmr 201-1000 AMPS
ZOy? ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.IT.
1 understand m I shall be used as blit records.PEI6OVER 1000 AMPS
OZ-0 ypanss a public
J SIGNS ELECTRICAL
....II Licensed lkol'casional
EU OWNER.BUILDER form
DECLARATION SPGCIAL CIRCUIT/MISC.
apaaS�..O aU 1 hereby Affirm Se tat 1 am exempt from to Conwnm's Wmnse Lew for to
res 3 LL y which regrown.(Section]0715.Business and Pmfessions Code:My city.,stcounty TEMP.METER OR POLE INST.
O which rtquisane,Asoreuirlstheeller,impose,demolish,firepair BeysNctart
W �f prior toslicennd palm pt to the
applicant of theuch Permit file ase La smmment POWER DEVICES
O<p that he is ncingw pursuant m the previsions of the the B.,cmrs License Lew(Chapter
9(commencing with Sermon](Nl(1)ofDivision did the Business end Professions Coda) SWIMMING POOL ELECTRIC VALUATION
WMV, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCIiBS-FUCfURES
I Y Section]031.5 by any applicant forapemdtsubjecm the applicant m acivil Nnmtyof
Eft notmomthan five hundrcddollars(5500). NEW RESIDENTIAL ELEC9R Q.
C pm ❑ I,asownemfthepmpeny,ormyemploymswitwaguntheirsolecompenuu on, TOR TYPECONSTRUCTION
y 30-2 will do thework,unJ thesvucmre is hot imandsolm.fferad for We(Sec.]044,Business
and limitations Cole:The Contractors License law does not apply m an owner of C /
property who builds or improves thereon,and who does such work himsel for through his C P RES.UNITS
own employcex,provided that such improvememe aR notimended oroffcrcd Tarsale.If,
/ NV/
however,thebuildingorimprovemem is sold within one yeero(completion.the owner- /1�
builder will have the burden of roving tat redid not build or improve for purpose of (-
sale.).
❑ I,asownerofthepropcny,m exclusivelyc ntmmingwithlicenx con=comto QTY. PLUMBING PERMIT FEE ILOOD ZONIi APN
covshum the project(Sec.0044,Business and Professions Code:)The Contmctore
License Luw Jnesnm uPPlymen nwnendpropeny wbobuildsorimproveathemon,and PERMITISSUANCE 1.
whoconrafret such projecs withuconvacmr(s)licenced pursuenrrothe Convecmr's
License Law.
ALTER-DRAIN&VENT-WATER(PAJ FCB SUMMARY
❑ 1 sus exempt under Sec. ,B&P C for this reason BACK FLOW PROIPCI'.DEVICE SANITARY Y OUTSIDEES
N
Owner Date RF.CF.IPf N
DRAINS-FLOOR,ROOF,AREA,CONE.
WORKMAN COMPCNSATION DECLARATION 5CHOOLTAX Y N
❑ I hereby affirm that i have a certificate ofcaesentto self-insure,or a certificate of RECEIPT#
FIX'1'URFS-PER TRAP
Workai Compensatinnlnsumttee nruccnified copy thcrcof(Sec.3g00,Lab C.)which PARK FEE YN
covers all employee's under this permit. C GAS-RA.SYSTEM-1 INC.4 OUTLETS - RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-FA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certifies copy is hereby famishes.
❑ Certified copy is filed with to city inapectiondivision. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This secrionneesreor becempletW ifthepandan is forone hundred dollBn($UA) SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
or less)
I certify that into performance of the walk bar which this permit is issued,Isbell WATER HEATER WIVENT/ELECfR
not employ any person in any m e
n o as to becomsubject to the Worked' PAID
Compenadionl.Bwsof Celifomie. DoreWATER SYSTCM?BEATING Date Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
1--i rA become subject o the Workers Compensation provisions of Labor Cade,you must
forthwith comply wit such provisions ar this permit shall be doemed revoked. BUILDING ME
CI-I Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for to performance of
the work for which Formal this Foal is issued(Sec.3097,Civ.C.) ELECTRIC PEE
C2. O Lender's Name
O Lenders Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
1 coolly that I have read this application and state that the above information is
7" L2I
correct.lagrcemcomplywithellciryandcoun tyroximmmsandstntehwe rtlatingm PLRMIT ISSUANCE /� MECHANICAL FEE
U) building construction,and hereby outhoriu representatives ofthiscity,in enter upon the
V above-mentioned property for inspection purposes. ALTURORADDTOMECII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep hurmlean the City of Cupertino against
liebilifies,judgments,costs and expenses which may in my way, ins idCity AIR HANDLING UNIT('I'D Ul"CFM)
in co uen of the gmnring of tis pc —1 A2 AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanVCanmocmr Dam EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('1'O I(g3,0fk3 BTU) Dole keceiptto
Will the applicant or future building occupant store or handle hoard—materiel
m defined by the Cupertino Municipal Code,Chapter 9.12,Bad to Health and Safety I]RATING"IT(OVER 100.0330 BTU) zf TOTAL:
Code,Section 25532(a)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will teupplieuntor futrc hnilJingrccurnm meeyuirmenmrdev'meswhich emit
BOILER-COMP(3HP OR IM."BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Arca Air Quality ManagementROLLUR-COMP(OVER IOD,MOBTU)
Control? 0111 p Q D
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. V' {'9
1 have red the hamodoSafety
,materials 5505requ,25533 under 34, 1 un erst of the SEP e T
if the
California Health&of cur CWe,Sections 25505,that
25537 and 25534. 1 understand that �AYCCWW1a
ifthebuilding Anesnm currently have ast Ise thati0is myresponsibil ityI.edoily the
Occupant of the requirements which must he met prior m issuance of a Certificate of A
Occupancy. �fGl'tI IIYV
Owner ornmhnved agent Data ISSUED BY,