25517 (2) - •a a v -U1_1_IM lnrUHMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELhu rRICAL PERMITNO.
BUILDING DIVISION r� ,g
APPLICATION/PERMIT PLUMBING-MECHANICAL L 1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /. SANITARY NO, APPLICATION SUBMITTAL DATE
(-_e' UNITN LOT#
r
OWN'HS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO: N/C OLp
T/Erz co o/ CONTR
•ARCHITECT/ENGINEER: LIC NO: ADDRES : ❑
6 /s
CONTACT: PHONE:
_G C' QTY. ELECTRIC PE IT FEE
BUNG PERNFO
BLDG ELECT PLUMB MECH
PERMIT ISSUAIrC.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES- FN'I'IAL JOB DESCR�
OmZ Ii ereby 70M),ffDi Natl emlicc Business
professions
orle,arommecense with
ts100 Senion)00p)of DiviainnJof the Rosiness and Pmfueions Code,end mylicenee is in ppprglg TOW
FZwLlcenaXce and effect I Lic.N � 6 - Up TO MPS
rn=y DmeContm 2I 1 AMPS
ZO'Z' ARCHITECTS DECLARATION O OOO AAffa SQ.FT.FLOOR AREA SJSQ.FT,
O Z�- I..&..and eny plans shall be used as public accurst.
6 Licensed Prnfesvonal S ELE IC
2C OWNER-BUILDER DECLARATION SPECIAL TSC.
x 314E I hereby affirm that I am exempt from the Contractor's License Law for the
F-0.Ow¢ following reawn.(Section7001.5,Business and Professions Code:Any ciy.reaunty TEMP.MRPO INST.
y J which rtquue a permit to conswct.thea,impmve,demolish,_.repay any son _
s�Q� ma
Prior to its isnce.ulso requires Neapplioant i
for such Permit 1.fit POWER DE CES
g'OO that he is licensed pursuant to the provisions of me Contractors License Law(Chapter
dkoC 9(commencing with Section 7")ofDivision3 of Ne Business and professions Cole) SWIMMING LELECIRIC V UATIGN '
Wim or Nut he is exempn m unfimand the basis for the alleged exemption.Any vidittionof
jUiga el Z 4 Section 7031.5 by any applicant for a Permit subjects the applicator tOUTLETS.SWITCHES Q
o a civil Family of C)
not more Nan five hundred dollars($5041). NEW RESIDENTIAL ELECfR SQ.FT.
❑ 1,usownerofinepmpeny,onnyemployeeawith wages as Neirsolecompareadon,
STORI TYPE CONSTRUCTION
n _ will dothellmus Coal. he Contin den's License,
La end s res,apply in 44,Bnshteof
and Professions Code The Comractor's Licenu Law does not apply m an owner of
pmpeny whoas,provided
improvesownthereon,vndwhodoeasuch work himeelfor 0vough hie
atop,oyeea,pingoriprove armand ms mid tn con imandedoroDmed firarthe ow.If,r- aOCC.GROUP RFS.UNITS
however,meavetie burimpmfoulinismldwithinioneyem ofwprove for
theowner- L.builder will have the bonicn of proving thm he did nor build or improve for purpose of
ale.).
❑ haaownerof the pmpmyens exdusivelycontnming with licenud cunaacmnto QTY. PLUMBINGPERMIT FLOOD ZDN. APN
construct the project(Be..7044,Bae ase and Professions CodeU The Contractor's
License Lewdoes not applyto an owneroftempeny whobuildsmimprovesthenon,ertd PERMIT ISSUANCE
whocwtmes for such Projects withs1todro toO)licensed Interactions othe Convacmh ALTER-DRAIN&VENT-
Lierns.Law. RATER(EA) NEE SUMMARY
❑ I am exempt under See. ,B&P C for Nis reawn BACK FLOW PROTECT.DEVICE SID-FEES
S RY YN
Owner Det pRAINS-FLOOR,ROOF,ARFA,C ND. RECEIPTp
WORKMAN COMPENSATION DECLARATION Y N
❑ IhercbyafEsal Nmlhavere electrteofconunnoof(Sceum,am Lab
which FIXTURES PER TRAP I RECEIPT#
Worker%Cumpcnsminnl once orecenifed copy thereof(Sec.3tl00,Leb C.)which A F � Y N
rovers ell employe' oder mit perm it' GAS-EA.SYSTEM-I INCAOUTLETS RECEIPTN
lBUILDIN DIVISION 'S
-Company GAS-[A.SYSTEM-OVER4
❑ it it copy is hereby famished.
nifed wpy is fled with
Ne city inspection division. GREASEANDUSTRL WASTE INTF.RCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifNepertnit is formes hwdredd.11.(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les'.)
I unify that in Ne performance of the work fm which this permit is issued,I shall WATER HEAT ER WIVENWELECIR
not employ any person in any towner ao ss m become subject m the Workers' PAID
O Z Compensation Laws of CalifmNa. Data WATER SYSTEM[MEATING Date Receipt p
Applicant
zC NOTICE TO APPLICANT:If,after making do.Certificate of Exemption,you shoulJ NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(-' Vj) become subject to the Workers Compensation provisions of the labor Code,you must
F-i forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
GW.. Q CONSTRUCTION LENDING AGENCY SEISMIC FEF.
z I hereby affirm theuheae is ec9�auction lending agency for me performance of
U O be work for which this pemtit is ep(Sec.3099,Civ.C.) TOTAL: ELECTRIC FEE
I, s... Ienders Nemo !i
O Cr, Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
1 cenify that I have reed t(s application and area Nm the above information is
correct.Ivgrcemcomply with ell city eM wwryoediaunm eM sate levo rtladngm PERMITISSUANCE MECHANICAL FEE
i,i building construction,and hereby authorize representatives ofthiscity memerupon the
U Z aluve-m.mi.ned properly for inspection purposes. ALTEEORADDTOMECH. CONSTRUCTION TAX
(We)agree tan save,indemnify and keep humless the City of Cupertino against
Iiubilities,judgmesns,cons andexyenus whichmay in any way accmeagainst said City AIR HANDLING UNIT(TO I IMI)CFM)
in conuquenc<olt rvntin of this anis. `
1/n�4C/• t .7`/
AIR HANDLING UNIT(OVER 10,"CFM)
Sign of Appli�canaha rr Y Dot. EXHAUST HOOD(WIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO RaLM0 BTU) Date Recci N
W ill the applicant or future building occupant more or handle hesandous material
as defined by he Cupertino Municipal Cantle,Chapter 9.12,and the Healm and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532m)?
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR IOL"BTU) ISSUANCE DATE
Will air contaminacant ornts
is as building by the ay Anaequipmentuality es Management
. hvu riot?sir comeminoma az defined by the Bay Arte Air Quality Management BOILER-COMP(OVER IOLMD BTU) PAID
I District?
❑Yea ❑No NEW RESIDENTIAL MECH.-SQ.FT. /'
' 2
199
I have mad the Instructions materials acquirements under Chapter 6.95 of the SEP
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
-irif the building does not currently have a tenant,that it is my responsibility to notify the
IiY Ur sur'
occupam of the rcquircmems which mut be met prim in issuance of a Certificate of
Occupancy.
Owner err euNoriud agent Dote TOTAL: ISSUED BY: