25445APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OD.IG-A
OFCUPERTINOPLUMBING MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT tlI1101NG PROJECT IDENTIFICATION
PERMIT NO.
25445_ J44J
BUILDINOAD''U')RESS:
SANITARY NO.
APPLICfpV1(ON SUBMITTT^AA�LLDD_AIE
/ ��77
3/X L fj(f(_ IUNITN LOTH
t/ I Imo.!
v� 1_ r✓
OWN[ > ME:� - PiINE:
E7✓e%
MJRA OR'S NAME LIC NO:
�/�.11
NIC
❑
CONTROL
ARCHI'117C DENGINHE . LIC NO:
AD ItI
�L/•
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT P-LUVB MECH
tn, 73— �
W
PERMIT ISSUANISSUANCELICENSED
CONTRACTOR'S DECLARATION
lumby.ffien Nm 1 Bin licenseduaderpmvisions ofaspler9 (commencing with
Section 7 W0) of Division 3 of the Business and Professions Cods, and my license is in
APPLIANCES- RESIDENTIAL
JOB DESCRIPTION
PANELS
full(.wand effect.
I
License Class_Lt.. p
UP T0200 AMPS
"�
Dmc Contractor
201 - 1000 AMPS
ARCHITECT'S DECLARATION
1 understand my plans shall be used ut public remands.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
e g�
ICL I11—!!,I
License) Professional
OWNER -exempt ROEC
/
SPECIAL CIRCUIT/MISC,
ContraON
I hereby effimt that 1 nm exempt Irwn the Contrecmra License Lew for thet
p1I pI�
METER OR POLE INST.
TEMP. MCifFM
following reason. (Section 7031.5, Business and Professions Code: My city or county
P V T E R
prion. r ii.. pennota, .1.1,
1,ahlicevtfrove, dpemtina maps gnsd eutement
poor to it,imae. a[,. mm.B.he applicantst ,demolish, Man uSany summon,
fiat
POWER DEVICES
that he is licensed pursuant o the provisions of the Contractor's License law (Chapter
9(commencing w itis Section 7") of Division 3 of the Business and Professions Code)
pC I\)
WE
SWIMMING POOL ELECTRIC
Uq7
or that he is exempt therefrom and the basis for the alleged exemption. My violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
OUTLETS - SWITCIiFS -FIXTURES
nes marc than roftheve dmddollarmyem J.
❑ LesownemDhepropeny.ormyempendeeswithwagesesthei(sole
NEW RESIDENTIALELECTR_SQ. FT.
STORIES
TYPECONSTRUCIO
044, Business will do the work,andshe he Curcio not is
7044, Business
and ljcmoar afetedforole(Sec.
Cale: The Conumcma, License Law not apply 1f an owner of
ernfessinm
such
propenywyee.,pdvn e]the, mNereogamlemOmessmchwmkhimselfwthrmic.Iscosm
forilmow.If,
roBad
es,pingor
OCC. GROUP
RFS. UNITS
TOTAL:
however. the i prvement witemncycarisfo.(offered
issoldwithin oneyur ofcomplefor Neawner'
howevertheave be burden
builder will have the burden of proving that he did not buil) nr improve for purpou of
QTY, PLUMBING PERMIT FEE
ale.).
❑ I, esnwnerof the property, Bin exclusivelymtmreming with licensed contractors to
FLOOD ZONE
qPN
onswet the project (Sec. 7044. Business and Professions Code:) The Cmumcmea
License law dw,motapplym000wnmofpmpmty whobuiidsmimproves thereon,end
PERMIT ISSUANCE
whocontmatsfmx.ch projects Mmitcontowtu.) licensed pursuant m the Conumaors se Law.
License
ALTER - DRAIN & VENT -WATER (EA)
FEE SUMMARY
❑ l nm exempt under Sce. , B & P C far thio reason
BACK FLOW PROTECT. DEVICI!
S DE FF.L
SANITARY Y N
RECEIPT#
Owner
DRAINS-FlAOR, ROOF. AREA, COND.
WORKMAN COMPENSATION DECLARATION
AT
SCHOOLTAX YN
❑ Ihen,by affirm Nedihevcacenificme ofconsent meelGinsum, orattnificate a(
Workers'Compcnsatian Insmomewacenifed copy Nereof(Sm. 3800, Lab C.) which
RECEIPTp
�_
FIXTURES -PFR TRAP
PARK FEE Y N
covers all employee's under this permit,
Policy p
RECEIPTN
GAS - EA.SYSTEMd INC.401ff1.FT5
BUILDING DIVISION MES
Company
GAS - M. SYSTEM -OVER 4 (M)
PLANCHECK FEE
❑ Certified copy is hereby famished.
GREASE/INDU.STRL WASP: INTERCEPTOR
GRADING FEE
❑ Ccnified copy is filed with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM HA. 2WFT.
ENERGY FEE
(Thissmtimmart.ot be completed ifthe permit is for one hundred dollars (1000)
or less.)
WATER HEATER W/VF.NP/rLECTR
I ismifyflm in the Polommnmof the work for which this permit is ismov. i shall
not employ any person in my manner so as to become subject to the Wmkms
PAID
Compensmianlawsof Culifamia. Dote
Applicant
WATER SYSII?M/TRFATING
Date ReceiptY
NOTICE TO APPLICANT, If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL MMIL SQ, FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such Provisions or Ibis perrtN shall be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for Ne performance of
work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
T
ELECTRIC FEE
Lenders Address
QTY. MECHANICAL PERMIT FET?
PLUMBING FEE
1 cmify that I have read this application and state tom the above information is
co
correct, Im agree to comply with all city and county ordinances and state laws relating
PERMIT ISSUANCE.
MECHANICAL FEE
ommintma,and hereby authorize rcpmenmtives ofthia city mender upon the
elwve-motion l property for inspection pnpoms.
ALTER OR ADD TOMECH.
CONSTRUCTION TAX
(W a save, e, indemnify and keep humtlm the City of Cupertino against
liabili' jt t, sound n s which may inanywayaccompinsa dCity
AIR HANDLING UNIT(TO 10.0I10CFM)
e
ioc I rani of thi potion,
!,
Lyh/ AA
AIR HANDLING UNIT (OVER 10,000 CFM)
' roma( Dote
EXHAUST HOOD(W/DUCI)
PAID
HEATING UNIT (TO IW," BTU)
Date Rmeiin#
HA9ARDOUS MATERIALS DISCLOSURE
Will the upplicunt or future building occupant stun, or handle h uromous material
detinud by the Cupertino Municipal Cwle, Came, 9.12, and the Health and Safety
1ICA'fING UNIT (OVER 100,00a) NTU)
TOTAL
VENTILATION PAN (SINGLE: RPSID)
Code. Section25532ho?
11 Yes ❑ No
Will thenpplicoomrfwumbuildinguccupootuseequipmem.(devices whichemit
DOILER- COMP OHP OR 100.000 BTU)
ISSUANCE DATE
heze(daus air comumim.ms as defined by the Bay Arca Air Quality Management
Diatriml? 1:1P
❑Yes No
BOILER - COMP(OVER IUgObo BTU)
A B D
NEW RESIDENTIAL MECII. SQ. FT.
I have read the himandous materials requirements under Chapter 6.95 of the
California I leolth A, Safety Code, Sections 25505, 25533 and 25534. I understood that
if the building does not currently have a tenant, that it is my responsibility to ruddy the
AUG 11 IM
mcupam rel the reyuirements which mmol he met prior to issuance of a Certificate of
Occ.Pmcy.
Cl I - � lEvy
ISSUED BY:
Owner or authorized agent Dae
TOTAL:
OFFICE