25384 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 3 8 4
BUILDING PROJECT IDENTIFICATION
B I61NGADDRESS: � � SANITARY NO. APPLICATInON SUB—M ii— PATE
U `!IY/1 UNITN LOTH
ERgN ME: '� i C(
7 �il'1J I1' N/C CONTROLq
-HITECT GINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PPVV MECH
PERMIT ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, JOB DESCRIPTION
p�Z I hereby affirm qual am licensed undcrprovisions of Chapter9(commencing with /, ,a �, / J'
Y100 Section]OOD)of Division 3 of the Business end Pr°feesi ns Cod d my licrnse is in PANELS ' ,[s� 4-O (� I/�/ a�"
FFy-.zc" full farce en f 1.
G Zy License Lic k UP TO 200 AMPS
rFii 6 d Dzc" ale Contractor 201 1000 AMPS
ZOr`nii'5 ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—C Iunderstand my plans shall be used as public records.
r m SIGNS ELECTRICAL t\ "
Licensed Professional t i+
GGG
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
yy OaContractor's I hereby affirm that 1 am exempt from the Conrtemor'e License Law for the r
txi13 O
on following reason.(Section 7031.5,Business and Professions Code:Any city m county TEMP.METER OR POL8INST.
m.Q] which requires a permit o construct,alter,improve,demolish,or repair any structure W160
prior to mi
its issuance,also requires the applicant for such pert to file a signed statement POWER DEVICES
p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a, g 9(commencing with Section of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC ATION
m_rn or he is exempttheref on and the basis for The alleged exemption,Any violation of OUTLETS-SWITCHES-FIXTGRES
GSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
mnot more than five hundred dollars($500). NEW RESIDENTIAL ELECTR S .FT.
❑ I,mowaerofthepropeny,ormyemployeeswithwages�theirsolecompensatim, Q STORIES TYPECONSTRUCTION
ywill dothe work,and the structure isamintended a rofferedforsele(Sec.7044,Business
.it Professions Cords The Commctor's License Law does not apply to an owner of
property whobuilds^rimprovesthercon,andwhodeessuch work himselfordhraaghhisown -
employees,providedlharve impis sold itsorenoticarofo mpactere-]the owner.
OCC.GROUP RES.UNITS
howevmillhav l the burden
ofpmemishat he id noncyear of improve foron.theowaeo TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑construct
the profflas ject(See.70 em exdessandvely contracting withre:) eoContetorsto
construct the project(Sec.oaro Business and Professions crimp The Contractor's and
License Law doesnot apply toenownerofprogeny,whnbuildsorimproves Hereon,end PERMIT ISSUANCE
whocommen,imsuch projects with nominations)lieensedpursuant Bothe Contractor's FA ALTER-DRAIN&VENT-WATER
License Law. (PAT FEESUMMARY
❑ 1 am exempt under gee. ,B&P C far this mason BACK FLOW PROTECT.DEVICE OUT FEES
SANITARY Y N
Ownu Dnr p12plNS-FLOOR,ROOFAREACOND. RECEIPT It
WORKMAN COMPENSATION DECLARATION , ,
SCHOOLTAX Y N
I?'Ihereby offrmthat l have a certificate of consent to self-insure,or a certificate of IIXTURPS-PLR TRAP RECEIPT#
Work,rs'Compcn...km Insurance m a cenifiedcop,dannmf(Sec.3800,Lab C.)which PARKFEE Y N
coven.all IetpRpyQep unnuNVv@oermit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT N
Policy p I+T-'[�J� - BUILDING DIVISION FEES
Company 141 b T GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cyfi ion copy is hereby famished.
Cenifed copy is filed with the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This secti°nneedn°t be completed ifthe permit is for one hundreddollas($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or lees.)
I cenifythat in the lcdo...ofthe work Por which this permit is issued,Ishdl WATER HEATER W/VENT/ELECTR
not employ any person in any..one,a.ro to become subject to the Workers' PAID
Compensatlonlawsof Calimand.. DateWATER SYSTEMIMR&TING Date Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
rA become subject to the Workers Compensation provisions of the Labor Code,you must
bodwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
R✓✓ 1 hereby affirm that there is a construction lending agency for the Performance of
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
lenders Name
D" Lenders Address QTY. MECHANICAL PERMIT PER PLUMBING FEE
O V 1 certify that I have mad this application and state that the above information is MECHANICAL FEE
FOWi coma.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
e)agree m save,indemnify and keep harmless the City of Cupertino against
li it ,judgmems.coms andexpwaee hmay in any way accrues tae' City AIR HANDLING UNIT(TO IQ000 CPM)
n qp re of he grant of is it f I AIR HANDLING UNIT(OVER 10,OWCFM)
Si,entreof Applic Canty r Dar EXHAUST HOOD OAMUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Ifft"BTU) Date Receipt#
Will the applicant or forme building occupant store or handle he andous material HEATING UNIT(OVER I W,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)] VENTILATION PAN(SINGLE RESID)
El Yes ❑No
ISSUANCE DATE
Will thcapplicanter futurebuddingoccupant useequipmentordeviaswhicherdt BOILER-COMP(3HPOR IW,WOBTU)
sanders air coundamenB as defined by the Bay Area Air Quality Management BOILER-COST(OVER IW,M BTU)
Tarim] PAID
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the 'ASA ��
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that J(yl
if the building does not currently have a remand,that it is my responsibility ecnotify the
occupant of the requirements which must he met prior to issuance of a Confuse of y
Occupancy. �jI II�V
Owner m au0odzed agent Data TOTAL: ISSUED By-
OFFICE