25634 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDI ,- .LF.CTRI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF,C'T IDENTIFICATION 25634
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O/ • UNIT# LOT# ���t�(
O NE E: PHON CO R OR' N E: LIC NO: {{{ —{{{—
ARCHITECTIENGINEER: NO: A DRES � O N/C CONTROL#
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL -� JOB DESCRIPTION
mZ Imoth,affirm that l am licenudunderprovisimumfChapter9(commenting with 00 SOe11.pTWdjtaf DivinionJo'f the Business end ProPossionsCWc,end my license is in PANELS
'ZWfull force and ef4t. �-aLb# lUle 1 UPTO200AMP5
Qp_zw assn. V
y<y Dme- Contracrer� 201-I"AMPS
Z FOyez ARCHDECTS DECLARATION OVER 1000 AMPS SQ,IT.FLUOR AREA E/SQ,Ff.
CZ-0 1 understand my plans shall be used m public records.
SIGNS ELECTRICAL
Qy , Licensed Professional
OWNER-BUILDER DECLARATION SPECIALCIRCUMMISC.
F 1 hereby off.that 1 an exempt from the Contractor's License Law for the
�xx'Oa
W 3 tor.m following reason.(Section 7031 5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter.improve,demolish,or repair any stmouse
prior to its issuance,also requites Ne applicator Rusuch pwmiuo rile a signed statement POWER DEVICES
ml
60m Nu he is licensed pursuant so the provisions of the Convectors License Law(Chapter
6�LL 9(commencing with Section T000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
orthm he is exempt hemrmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTI)RES
{.Z>, Section 7031.5 by any.pplicant far.man is subjects the applicant a civil penalty of
I,❑pj 0
hot more than Eve hundred dollars(S500). NEW RFSIDLNTIAL ELECfR CONSTRUCHON
o ❑ 1,mownuofthepmperty,ormyemploymswishwagcsastheirsolec=Nmo0on, _SQ.Ff. TBIDFS TYPE
y3v0 will d.thewons ondr,e "Camra notim Lando I...does
apply
044,Business
and Professions wh ons Code:The Contractor's License Law does not apply to an owner iof
s
pm)xny who builosnrimproveshhercon,andwM1odnes sochwork himsdfor through his OCC.GROUP EIPN
employees,ldingoed prove imptovements tan ager eart,fdmaffe�for ole. r.
however the building m improvement is set he did.at build ofimprovd.n,the owner. TOTAL:
builder,will have the burden ofproving that he did not build m improve for purpose of
oleo).
❑ I,.towner nftheproperty,am exclusively connecting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lew doesnmapply to artownerofpopeorty who builds m improves thereon,and PERMTTISSUANCE
who contracts for such smact.with aconvemoots)licensed pursuant o the Contrecmes
License Low. ALTER-DRAIN&VENT-WATER(EAj FEE SUMMARY
❑ 1 um exempt under Sec. ,B&P C for this rasa.. BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Data RECEIPT p
• WORKMAN COMPENSATION DECDRABgS-FLO00.,ROOF.
LARATION AREA,COND. SCHOOL TAX YN
❑
Workers
Conaffitat ton Insurance
or i0cmeaf copytherof(Sesuu,ar as C.)wick FIXTURES-PER TRAP RECEIPT#
Wurkers'Compcnotinn lnsurancc oracertified copy thereof(Sec.38W,Lab CJ which PARK FEE YN
covers all emyoycgsypdar spieyrmit GAS-EA.SYSTEM-1 INCA OUTLETS RECEIPT#
P.licyp PCl'Fdll J s BUILDING DIVISION FEES
Compwy (m�L ✓ GAS-EA.SYSfF.M-0VER4(FA) PLANCHECK FEE
❑ Ce tied copy is hereby muddied.
e had copy is Bled with she city inspection division. GREASEfINDUSTRL WASTE INTERCEPTOR GRADING EEE.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This semi.mi nee deal becompleted ifthe permit is for am hundred dollars(SIW) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or less.)
I certify shm in the paformnceof the work for which this permit is i...W,I shall WATER TERWIVENTAGCECTR
not employ any person in any manner so u to become subject to the Workers' PAID
Z Compenotioa Lawsof Califsdam. Date TE
SY /TREATING m Date Receipt is
Applicant
� 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) ba.mesubject to the Workers Compensation provisions of she Labor Code,you must
Forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
t1 hereby affirm that hem is a construction lending agency for the performance of
L) O the work for which this permit is issued(Sce.301 Civ.O) ELECTRIC PER
OLander'.Name PLUMBING FCC sa—
[6 Lender's Adduss QTY. MECHANICAL PERMIT FEE
1 certify that I have mord this application and state that the above information is
R. correct.I agree to comply with all city and county ordinances and stem laws relating to PERMIT ISSUANCE MECHANICAL FEE
U 2 buildingeonstructlon,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. ALTER OR ADD TO MECII, CONSTRUCTION TAX
(We)agree to save,indemnify and keep homeless the City of Casemate agvmt
liabilities,judgemcnts.css andexpenus whichmay in my way weemeagainst mid Cis, AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of she granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Simulate of Appliesnt/Convacmr Das EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATWG UNIT(T0100.000 BTU) Data Raeipl#
Will he bflas Crimeina ice,Mometoing Cade. pamemasr9.o,hanand to Health usmavdal DEATING UNIT(OVER IW,000 BTU) TAI.
m defined by she Cupertino Municipg Code.Chapter 9.12,and the Health and Safety
Coda Section 25512(pT
11Ya / VENTILATION FAN(SINGLE RESID)
❑ DN
ISSUANCE DATE
Will the appliwmorfuture buildingoceupanmuegoipmentnrdevices whichemit BOILER-COMP PHP OR 100,000 BTU)
stinct? air contaminants as defined by the Bay Area Air Quality Management
Distinct? BOILER-COMP(OVER 100,000 BTU)
Di
❑Yes ° NEW RESIDENTIAL MECH. SQ.FT.
1 have reed the humorous materials requirements under Chapter 6.95 of the PA
California Health&Safety Code,Sections 25505,8533 and 25534. Lundershoutho ® 0)
Flat,building dues not currently have o human,that it is my responsibility to notify the
a(upam f th f muss be prior to issuance of a Certificate of CT
,
'/�- CPV
Ownermauthoriudagem Data TOTAL: ISSUEDBY: U
OFFICE