25285 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITU OF CUPESION •
•- -- PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25285
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
LOT#
O E PHONE: CO OR'g NAME: LIC NO
0 96 `Tl`•�Ir N/C CON ROL N
ARCHITBCT/EPIUINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: ELECTRIC PERMIT PEE BUILDING PERMIT INFO
ELECT PLUMB MUCH
PERMIT ISSUANCE El
LICENSED CONTRALTOR'SDECofChip O APPLIANCES-RESIDENTIAL LOB DESCRI N
py.Z Ihemby affi to ivilml emlice Btsmessund iof arm
(co my Items.
ad Senfon700full force dofect. on3of the Business and Prof stuns de, my license is in PANELS
aVUtFp. License
Cl.deffeu. IIP TO200 AMPS
FZ,W License Cle Lic.M
m7y Date Contractor 201-IOOOAMPS
Z O y ARCHIT'ECPS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O z� I understand my plans shall be used as public records.
P 4 ® SIGNS ELECTRICAL
ag Licensed Pm(essbnal
0.Jcd
OWNER
-BUILDER DECLARATION SPECIAL CIRCUIT/M[SC.
xOyU I hereby affirm that Itun exempt from the Contractor's License Law for the
W 3 O vF¢i following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE WST, p R n
�m.] which requires a permit to construct,alcor,improve,demolish,or railcar any structure
ce2 prior in its issuance,also requires the applicant for such permit to rile a signed statement POWER DEVICES
d p that he is licensed pursuant to the provisions of the Ordinances License Law(Chapter
hM 9(cammebcing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING MOLE
or that he is exempt Nerefmm Cards and the bs for the at leged exemption.Any violation of VALUATION
Section
Section T031.5 by any applicant for a permit subjects the applicant to a civil penalty of SWITCH"PERMITFEE
a� not more Nan rive hundred dollars($500).
CO ❑ Lasowneroftheproperty,mrostn to ces with we esntheirsolecom NEWRESIDENTIAL
Y P Y B perutimcs. TORI TTPF.CONSTRUCTION
4'3-� will domework,and the Me cture Cmdisaotii runded License
rwdoesforsuale
nota(sec.9044,Business
and Profession Code:The Convector's License Lew such
not apply to an Owner of
Property wyebu pro or improves eddeam bbripa,and who des s irh work o,.ff Porthrough his
own
owemplOyeesi[ding edtponveh(mprovementsar mrsayercdcomplfered for owd If, 7FlOOD
CC.GROUP RES.UNITS
however,theave the burden
of poem issoldhe idoneyem of completion the owe of
'milder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,as ownerofrhe properly,amexclusively contracting with licensed contractors to QTY. PLUMBZONE APN
construct the project(Sec.7044,Business and Profession Code)The Committers
License Lawdceanotapply Nanownerofpmpertywho builds orimproves Nereonand PERMIT ISSUANCE
who contracts for such projects with a contractons)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) PER SUMMARY
❑ I and,exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
Owner SANITARY YN
Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMANCOMPEcawofeNDECLARATION SCHOOLTAX Y N
t ❑ Ihere'y affirm thatl heveacertificam of consentm self-insure,orecerlificam of IXTURES-PER TRAP RECEIPT#
\ Worcs Compensation insurance or a certified copy themof(Sec.380.Lab C.)which PARK FEE Y N
covers all employee's undo this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy Company BUILDING DIVISION FEES
Elrtified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division' GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(TTis section need not be completed if Ne permitis forma hundreddollars($100) EWER- ANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icerlify that in the performance of Ne work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECTI
not employ any person in any member so as to become subject to the WorkersPAID
Compareamon Uav,of Califomta. Data WATER SYSTEM/TREATING x
Applicant Data Receipt+
NOTICE TO APPLICANT:If,after making this Ceridiicae of Exemption,you should NEW RESIDENTIAL FILMS, SQ.FT, TOTAL:
F�^J � become subject re,the Worim's Compensation Provisions of the Labor Code,you must
forthwith comply with such provisions Or this permit shall he,deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY 0, SEISMIC FEE
z r hereby affirm that there is a construction lending agency for the performance of
U O the work for which this Permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's Name
ULenders AddressQTY. MECHANICAL PERMIT PEE PLUMBING FEE -
1 certify Net 1 have reed This application and Dam that the above infomud.a is
>1 a corer.I agree m comply with all city and county ordinances and sure laws relating m PERMIT ISSUANCE MECHANICAL FEE
buildingemearm tion add hereby authorize represenutives of Nis city toenearupon the
U ,z alcove-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,cosuand expenses whichmay in any way;Tcrm.gati asaid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequencea gr ting of thio pe i
AIR HANDLING UNIT(OVER 10,1100 CFM)
Sib ure of Applmam/Contucmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Rweipt#
Will the applicant or future building Occupant store or handle herrsMoua material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I O LNE BTU) TOTAL:
Code,Section 25532(a)'1
Cl Yes 11 No VENTILATION FAN(SINGLE RESID) �{
I' BOILER-COME(3HP OR 10.(100 BTU) ISSUANCED TE
Will[he applicantorfmturebuildingoccupent ueeequipmenmrdevices whichemit
harsrdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100/p0 BTU)
District? R1 A n
11 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Ifs #YIW
I have read the hazallous materials re - 'A�f)p
requirements under 34. 1 un erst of the v/ {bra& �IAaf
if the uil Health&Safety Code,Sections 25505,25533 itis and 25534. I understand that I�� .a
if the building g rices dm currencurds which
my have one met ms my reuance of a N notify the `�y✓1 7/ ,
occupant of No rtyuiren¢mts whish must be mu prior m issuance of a Certificate of C, y Vf
Occupancy. /J V
Owner or authorized agent
is TOTAL: ISSUED BY:
� tyv