25240 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINOILDI -ELVU I RI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUIEDINGPROJECT IDENTIFICATION 5 n ^J L l•�0
BUILDING ADDRESS, SANITARY NO. APPLICATIONSUBMITTALDATE
22 Y, s cLofewmO UNIT# LOT# r /Z
t WNERS AME: C NTRA R'S NAME: LIC NO: (/
as. � N/C CONTROL If
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
J CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
_ PL
L ECT UMB CH
PERMIT ISSUANCE �� ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ozz I hereby affirm that l am licensed under provisions of Chapter 9(commencing with
Y100 Section 7")of Division 3 of the Bmineavind Professions Cade,and my license is in PANELS -
tFy+V Loll farce and effect. r
F,ZLL] Licenselass CLic.# UP TO 200 AMPS
m G a Date Crown, r 201-IOW AMPS
Fya ARCHITECTS DECLARATION OVER I"AMPS
SQ.Ff.F1pOR AREA !S/(SQ
ZO 2-Q 1 understand my plans sM1sll bemead as public records.
tv
yY
l SIGNS ELECTRICAL
gC Liornsed Professional
C OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
W0 a U 1 ng um affirm that I am exempt From the Comment's Ca License Law for the
W 3 a vFi following reason(Section 7031.5,Business and Professions Code:My city Or county TEMP.METER OR POLE INST. '
Jwhich reyuires a permit to construct,alter,improve,demolish,or repair any structure -
to its issuance,alsore ires the lienot forsuch Permit file a signed statement POWER DEVICES a
prior qtr pp pract g
yy <p that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
y q SWIMMING POOL ELECTRIC
0 9(commencing with Section]000)of Division3of the Business and Professions Code) maw VALUATION
—Q or that he is exempt therefrom and the basis for the alleged exemption.Any violatimcd UTLETS-SWITCHES-FIXTURES `^O
7+ Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of `
not more than five hundred dollars($500). Q STORIES TYPE CONSTRUCf1ON
Q ❑ I,asowne,.fteproparty,ormyempl.yeeswithwagesastheirsolecompensabon, NEW RESIDENTIAL ELECTR S .
will dothe work,and the structure is artintended mofferedformle(Sec.T044,Business
and Professions Code:The Commum's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfor through his DEC.GROUP RES.UNITB
employees,provided that such improvements arc not intended m offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner- TO L
builder will have the burden of proving that he did not build or improve for purpose of
crofthe property,amexclusivelyconvacting with licensed contractors t. QTY; PLUMBING PERMIT FEE FLOOD ZONE APN
coni ct theproject(Sec.]044,Business and Professions Cade:)The Contractor's
Liven. Law does not apply,.armsmSofpropeny whobuildsmimproves Hereon.and PERMIT ISSUANCE
-wh earawactsfmsuch projecu withacontracmr(s)Iicensedpursuullothe Contractors se law.
Lice ALTER-GRAIN&VENT-WATER(FA) FEE SUMMARY
P
r
❑nl am exempt under Sm. ,B&PC for this reason BACK FLOW PROTE .DE P n e ^, I'l SAN DUTY DE FEES N
Owner Date DRAINS-FLOOR.RO F,AR .
.GONDRECF.IPI'#
WORKMAN COMPENSATION DECLARATION ISCFIBO YN
ElI hereby affirm that l have a certificate.fconsenrto sof-mium,or a certificate of FlXTURES-PER TRA RECEIPT#
Workers'COmpense,ionlnamnce orattnified<opy thereof(Sec.3S00,LebCJwhich P E YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 4C.40RECEIPT#
Policy# I'Mr- BI ILDING DIVISION FEES
Company GAS-EA.SYSTEM-0 ), PL
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEiR4DUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundraddollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance mda,work for which thispermit is issued.Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawa.f Califomia. Data WATER SYSTEM/TREATING Date Receipt If
Q z Applicant -
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject o the Workers Compensation Provisions lithe labor Code,you must BUILDING FEE
� ' forthwith comply with such provisions m this permit shall be deemed revoked. a0aii""
GWn Q - CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a comtrumma lendingenc
agy for the performance of C FEB
U zO the work for which this permit is issued(Sec.3097.Civ.CJ TOTAL: ELECTRI
Lender's Name
u' QTY. - MECHANICAL PERMIT FEE PLUMBING FEE
Lender's Address
LU1 certify that 1 have read this application and state that the above information is ' ' MECHANICAL FEE
cored I agree m comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE
ybuilding construction,and hereby euthorizerepresenmtives of thio citI'mrnwruponthe CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
.^� (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmencx.costs and expenses which may in any way accrue against said 'ty AIR HANDLING UNIT(TO 10,0011 CFM)
in coney the granting of this pe AIR HANDLING UNIT(OVER 10,0110 CFM)
ign u of AppbcvnUConramorDate EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSU
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle heaardous material HEATING UNIT(OVER]hit 00 BTU) T T
es dedned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Saint..25532nd? VENTILATION FAN(SINGLE RESID)
11 Yea ❑No
ISSUANCE DATE
Will theapplicamorfnare buildingoempant use equipmentordevices whichemil BOILER-COMP(3HP OR 100,000 BTU)
Incautious air contaminann as defined by the Bay Area Air Quality Management BOILER-COME(OVER IW,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hazardous mammis requirements under Chapter 6.95 of the "' ' D -
California Health&Safety Code,Sections 25505,25533 and 25534.I understand Own
if the minimal
does not neatly have a tenant,that it is my responsibility m notify the JUN 2
pbui of the requirements
man a which met m prior issuance of it Certificate e _
Occupancy.
Owner or authorized agent Dam ISSUED BY: l