25242 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
ILD .- HI A. PERMIT NO. 25242_
N C Z//1�T Z
CITY OF CUPERTINO PLUMBING-MEE MECHANICAL
HUH.DING DIVISION APPLICATION/PERMIT
BUILDING PROJNC'1'IORN'fIPICA'f10N L J
BUILDING
GAADDRESS: SANITARY NO. APPL1UNGUNSUBMTITAL OA TE
UNIT# LOTH
OyJtB,RS CME: '! ; P NE: CONTRACTOR'g NAME: LIC NO: N/C CONTROL e
ARCHITECORN'INEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:7 BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
'n
BLDG ELECT' PLUMB MECH
I PERMIT ISSUANCE [7D )L
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBDSCRIPTION
ptY,Z, Ihemby affirm that l um lmnsed under provisions of Chopper 9(commending with
m Section 70X).f Division 3 ofthe Business and Professions Cade.and my licame is in PANELS
Z F full force and effect. �� C/
�U UP T0200AMP5
License Class Lin.M
Loo<c Date C.mrscmr 201-1000 AMPS, SQ.FT.PL RARE E/SQ.FT.
ZFOyaARCHITECTS DECLARATION OVER 1000 AMPS
OZ-0 1 understand my plans shall be used as public records.
Qy SIGNS ELECTRICAL
oOQGG Licensed Pfofosslnnal
WW OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�iOyU 1 hereby if,.that I am exempt loom the Convector's License Low for the
jij
t� r'a following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
tsr J which requires s perrm m construct,alter,improve.demolish,or reuir any shucture
prior to its lsmamce,almoc tltoa applicant forsuch antro flea si dstatement POWER DEVICES
quires PP pe gne
thus her licensed pun coon 00 provisions n the be Bmitm's License Lawern (Chaplet
SWIMMING POOL ELECTRIC VALUATION
n�4e 9(rnmmencing with Section 700o)of Division 3ofthe Business end Professions Code)
u1Mso or that bei.aramoo hemfmm and the basis for the.11eged exemption.Any violmlon of
OUTLETS-SWITCHES-FI%TURFS J
Z�y.Y
Section 703 LS by wyapplicant for aprnnip subjects the applicennoacivil penalty of f
F� m.tmorc than five hundred dollars($50)). NEW RESIDFNIALELECTR -SQ.FT. STORIES TYPECONSTRUCION
In ❑ I,asownmofthepmop .ormyemployeeswithwagesastMirsolecomMmauon.
LB� will do the work,and the structure is not intended or offered for role(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds r improver dinner.and who does such work himealfor through his OCGGROUP RES.UNITS
owever,tyeboldin oriproveimprovemenuarcneinten 1coroflere,the mr.
however.theavete brimpmvememtissoidedidnoneyeat o,innprplerioar preowned TOTAL w�
builder will have the burden of proving that he did not build m improve for puryose of
sole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ 1,asownerofthepropersy,smesclusivelyconuactingwithlicensedc.nbamomt.
onsvun the project(Sec.7644,Business and Profeations Code:)The Contractor's
License Lawdoesnm apply roanownerofproperty who buildsur improves thereon.end PERMIT ISSUANCE
whecontmcu fm such projects with.comomior(s)licensed pursuant.rhe Convectors ALTER-DRAIN&VENT-WATER(IIA) FEE SUMMARY
License Low.
❑ 1 em exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SID
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,ARPA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
0IhercM1y effimnhetlhove ucerifcme of cnneem to self-insure,oracerti0cute n! FIXTUREEPERT P RECEIPT#
Workers'Compenmrion lnsurearm,ma certified copy Nereof(Sec.3800,Lab C.)which - PARK HE Y N_
^ RECEIPT 10
covers all employees under this permit. GAS-EA.SYSTE -11 G:A TS .' 1 t BUILDING DIVISION FEES
Policy#
CompanyGAS-EA.SYSTE -OV �(L•A)., .1 ,i tom. N ECKFEE
❑ Certified copy is hereby famished. _ •_
❑ CerifiWcopy is fled with the city inspection division. GREASPy1NDU5 W > RCEPTOR� l II GFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP 5 ILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($IN) SEWER-SAND' STORMEA.2(81IT. ?RGY FT
or less.)
I cenily that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIR
not employ any person in any manner so.to become subject to the Workers' PAID
Compeasmiou Lam.f C.ifomia. Dam WATER SYSTEM/TREATING Dam Receipt
ApplQz NOTICE
NEW RES IDENTIAL FILMS. SQ.FT. TOTAL:
Z NOTICEE TO APPLICANT:If.afermaking thisCertifi<mxem
cofEptian,youshould
I-+ y become subject@a WaimeaCamparmtion provisions of Ne Labof Code,you mast
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING PEG
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
az I hereby option out them is a construction[ending agency for the Performance of TOTAL: •V ELECTRIC FEE S-
V O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name PLUMBING FEE s
O F� Lender's Address QTY. MECHANICAL PERMIT FEE
W 1 cenily thin 1 have used Nis application and sure that the above information is MECHANICAL FEE
f�' a correct.l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE.
�+ buildingeonswction,and hereby authmiu mpiessmarives ofthiscity reenter uponthe CONSTRUCTION TAX
V above-mentioned properly for inspection Parisians. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino,against
liabilities.judgmenu,emu and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO 10,"CFM)
in consequence of the granting of this permit.
zz AIR HANDLING UNIT(OVER 10,000 CFM)
Signature o Applicant/ vacmr Date EXHAUST I IOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Dmc Rmcipt#
Will the applicant or future building occupant score or handle hvudleus material HEATING UNIT(OVER 100,000 BTU) TOTAL: 3a
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Swim.25532(a)? VENTILATION FAN(SINGLE RFSTD)
❑Yes ❑No
ISSUANCE DATE
Will theapplicanwrfuzee buildingoevup.muse equipmentordevivawhichanno BOILER-COMP(3HP OR IN,"BTU)
hiardous air connotations s er defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0IX1 BTU) P A I D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ��� aw a 811 ��.aJY�
I have read the harmrdous materials requirements under Chapter 6.95 of the /.1
California Health&Safety Code,Sections 25M5,25533 and 25534.1 understand that
if the building does not currently have atenan6 that it is my responsibility to notify the Ci)I ur 4.;Ut rTt 1119V
occupant of the requirements which must Fe met prior to issuance of a Certificate of
Occupancy.
Owne..'. ariud not Date TOTAL: ISSUED B .