25989 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONO11 - " PERMIT NO.
APPLICATION/PERMIT PING PROIS-MECHANICAA
BUILDING DIVISION BUILDING PNUJECB'IDRNTIFICATION 25989
BUILDING ADD S: 1 / SANITARY NO. APPLICATION SUUBBMHTAL DATE
D UL UNITM LOTH l�'�1
Lj
O -AMG: NB: TRACTO 'S E:1 IM 1 LIC NO: 111
f L fix 1s� N/C CUNIROL#
AliHITECT/EN IN LIC NO: A RESS . ❑
W �-
AC Alf PHONE: - _ 7 BUILDING PERMIT INFO
'xC 1 •�D l�� 1QTY.''.? ry ELB,CI'RIC PERMIT FEE
h'l11 U lN9,I`�1 - BL ELECT PLUMB MECIi
PERMIT ISSUANCE � f 1(
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pat Ihcmbyaffumtnal l amlicen ed under provisionsofChapter9(cammencingwith
j400 Section 90Xy.f Division 3 of the Business and Professions Code,and my license is in PANELS
a C[1 full force and eeffe�c s,, rte
fQFZtil License Clns�Lic.0!90 1,526? UP TO 200 AMPS
N 6 W Date Conrucon 201-1000 AMPS
OZ-0 ARCHITECTS DECLARATION OVER 1000 AMPS �z G�f 1'(U' ABBA 8 E/SQ.FT.
I understand my plans shell be used a9 public recoMe. !'\� „L
MU
SIGNS ELECTRICAL
CC,� LittasN professionala u1U OWNER-BUILDER DECLARATION SPECIAL CBICUIT(MISC. I'
X I hereby affirm that I am exempt from the Contractor's Liccme Law for the
cc?ay following exaan.(Section 9031.5,Business and Professions Code:Any city or county TEMP.MFMR OR POLE INST.
LLJ 0Oa which requires a permit to consvua.MteLimprove,demolish,m repair any soucture JEJ113
prismaiatenants POWER DEVICES
0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(conuncncing with Section 7")ofDivision 3 ofthe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION
y(�,n or that he is exempt herefomundthe basis for theallegedexemption.Any violmion of OUTLETS-SWITCHES-FIXTURES
F.aa Section 0031.5 bymyapplicamfor.pemtitanbu
jects theapplicano a civil peralryof
^^�W not more thnn Eve hundred unions($50b) Q STORIES TYPE CONSTRUCTION
_ NEW RESIDENTIAL ELECTR 5 .FT.
W pm ❑ Lthe wnvand the pperty,armyemtendedwithwegesssthei(Sm.compawness
d _ will dothywmk.ande:The
tinanense Law do for
not apply
oan Business
and Professions i&or improves
Convector's License Lew such
not apply tom owner of '
property who
es,Idsorimproves chcreomvd who daysinchwalk himeetfur florough
own employees,providW(hat such improvemmaerenotimended oroffcrcd(made.If, OCC.GROUP RFS.UNITS
boweveL the building m improvement is sold within oneyew ofcompledon,deowner- .TOTAL
builder will have the burden of proving that he did not build or improve fur purpose of
sale.).
❑ I,asownerofthepropeny.amexclusivelymn ctingwithliceroedcmtmwnw QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
antrum the project(Sec.70,14,Business and Professions Cede:)The Communes
Li<enu Lewdcesnot applyto anownerofpropertywhobuilJsorimprovm thetean,and PERMIT ISSUANCE
whomnno,ts forsuch pmjects with a connector(,licensed pursuant othecontmctors se law.
License
ALTER-DRAIN&VENT-WATIiR(PA) FEESUMMARY
EIi vn exempt under Sec. ,B,k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE'u.
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT-
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
'❑ Ihereby affirm that i have v cenificare ofcomentto self-imum,or a cnificate of FIXTURES-PERTRAP � RECETIT#
Workers Compensation Insurance ma cenified copy thercoffibc.3900,Lab C.)which PARK FEE Y N
overs all curly �eun it. GAS.EA.SYSTEM-I INC.4OUTLETS RECEIPTp
Policy N BUILDING DIVISION FEES
Company I GAS-EA.SYSTEM-OVER4 TAO PLANCHECK FEE
❑ Cenifte copy is hereby burnished.
❑ Certified cepy is filed with the city inspection Jivisinn. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not becompleted ifthe pounds is foronehmdreddollam(E1M) SEWER-SANITARY-STORM HA.2011 ENERGY FEE
or less.)
I certify that in the performance ofthe wank far which this permit is issued.)shall WATER HEATER.W/VENT/F.LECTR
nm employ my person in any roamer ao as to become subject to the Workers' - PAID
Compensvion Laweof California. Gets WATER SYSTEM/IREATING Date Receipt
' Q z Applicant
z NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,you shouldNEWMIDENTIALPLMB, SQ.pT. TOTAL:
become subject in the Wanke/s Compcnsvim provisions of the Labra Code,you mon
aforthwith emMills such provisions or this permit shall be deemed revoked. /tl O a� BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE.
I hereby affirm that them is a construction lending agency for the perfmmmce of
U Ohework for which this pemdt is issued(See.3091.Civ.CJ ELECTRIC FEE
I .
Lender's Name
- Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
O V I c nify that 1 have read this application and state that the above info rmakan is v
MECHANICAL FEE
Ila craned. Iagreewcnmply with nit chyaWcoumyoNinancmandstate laws relidngto PERMIT ISSUANCE
building construction,and hereby authodres
rerepenuw dvu ofthis city enter upon the CONSTRUCTIONTAX
V z
above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
-(We)agree to save.indemnify and keep hvmlms the City of Cupenima against
Iivbildicajudgmems.costs and expenses which may in any way aceneagaimtsaid City AIR HANDLING ONIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicaun Contractor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material TAL
ss defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)9
❑Yea ❑No VENTILATION PAN(SINGLE MID)
ISSUANCE ATE
Will theapplicm(orfuwre buildingcecupent use Wuipmenmrdeviceswhich emit BOILER-COMP(3HP OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Tisvict9 ❑ 11PAI D
Yee No NEW RESIDENTIAL MECH.—SQ.FT.
t 1 have read the hazardous materials requirements under Chapter 6.95 of theC. B a�
if the
building
gdos of cry Cody,aea teasel,
fat it is andZ534.responsibility
1undersand Nm {JH t I
ifcupant dithe re not ly haveaamm�thmiiis myrcepnceoiliryvnficalefy of {/ a
Occupam of the requirements which man he met prior w issuance of a Ccnificvto of
ccupancy.
I. Owner or uuthstired agent Date TOTAL: ISSUED BV � - V
OFFICE