25566 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHANICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 25566
BUILDING PROJECT IDENTIFICATION
.DING ADDRESS: /r�/ SANITARY NO. APPI.ICATIONSUBMITTALDAHS
I UNIT# µas �� LOT# / CI,an
OWNERS A PHONS ^ OS)aIACfOJt' N LI NO: N/C ` CONTROL#
/6G
AR II'TE GI EER. LIC NO: ADDRESS: 0
-ONTACf: PHONE: QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
s. BL ELECT PLUMB MECH
PERMIT ISSUANCE i E
LICENSED CONTRACTOR'SDECLARA erg APPLIANCES-RESIDENTIAL W` PI'IpN
OaZ Ihcrcby affirm Nolenlicensed DEsofChaprer9(commencingwiN M
0O Section]11007 of Division Sof Ne Business and Professions Cade,and my license is in PANELS
y,W E full force and effect.
FU UP TO 2M AMPS
Zfy License Class Lic.M W
,'y Dau Contractor 20 -1000 S SQ.FT.FLOOR AREA $/SQ.Pr.
,ZFOy,ZK ARCHITEarS DECLARATION
O Z—qW 1 andemm�d my plans shall be uuA ns public records.
�NSIG EL ]CAI.
q'Y
Licensed Pmfessionnl
C OWNER-BUILDERm the CATION SPE 'Al.CIRCUIT/MI C.
Oyu 1 following
affirm Nat 1 am exempt from The Conions Co License Law for the
tai SayQ whichinguitexa anal n 7031.5.toconstrut,alte,improve,
demolish,
or
city or county TEMP.METIER
F-�Oy J which rtyuires a permit to construct,oho,improve,demolish,ar rtpeir my sfmcturc
�;!(T7 prim to its issuance,also requires the applicant for such penniuo file asigncd crvument RD V
'p2 a that he is licensed persuanuo Ne pmvidons of the Commons License Lew(CTapur
W�qOK 5 1 1 POOL ELECTRIC VALUaji QbL
L1 MV, 9(commencing
xemwith
ereSection]0ndthe)of Division th.0leadexample.ess an Any]ou Cod:) /-'{S
,-may Soho h7031.5 by Nerefrommdthe Front subjects
dexemptt to civil penalty
of O -SWITCHES-FIXTURES
F Z QE g. Section]031.5 by any applicant for n pcmtit subjats the applicant a civil penalty of
nm to ' five hundrtd dollars(k5(XI). NEW RESIDENTIAL ELECTR S .PT.
erofrheprnpeny,ormyempluyeeswith wagexastheirsolnearmcresmim, Q STORIES TYPE CONSTRUCTION
y3_e JlNrtbework,and the structure is not imendedoroffered forsole(See.]1A4,Business
and Pndessimns Cade:The Contracor'x License Law does nm apply to an owner of
proprny who mi]dsorimprovesdserean,and whodoee such workhimselforthrough his
own
employees, revided Nmmch improvementsaremot intendedorofferedfosole.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ,of complebon,she owner
battler will have he burden of proving Nal he did not build or improve for purpose of
edeJ.
❑ I.es awnerofde Property,mnexclusively, contracting with licensed contracmr.m QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Cude:)no Contractor'.
License lewdms notapply toanownerofpopeny wholooddsoimproves thereon,and PERMIT ISSUANCE
who contracts for such ProjecuwiNacoomurms)Ilcensedpufnum0othe Commutes
License I.aw. ALTER-DRAIN&VPNT- ATER(EA) PEE SUMMARY
OUTSIDE
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PRT .DEVICE F. S
SANITARY Y N
Owner DamRECEIPT#
, 0
WORKMAN COMPENSATION DECLARATION DRAINS-FLOG0 , ,COND. SCHOOLTAX YN_
CI RECEIPT ton Iiurance or a certified
copyflamufFimum.m Lab C.))which FIXTURES-PER TRAP RECEIPTp
Waxen'Comloyce'ituder thiseoraccrtifcd copy tbereof(Sm.JP00.1.ebCJwhich PARK FEE Y N
covin all employc2s undo this pnmil. GAS-EA.SYS'11iM-I INC.4 OUTISETS Rf:CE1Pf a
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 PLANCHECKFEE
❑ Cenifird copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE C R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not areempleted ifthe permit is for onehundreA dollars($100) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
or los.)
I certify that in the prdonnanceofthe work for which this permit is issued,l shall WATER HEATER W/VRNT/ELECTR
not employ any Person in my manner so as to for.subject to the Workers PAID
Compensation Lawsof Califomia. Duro WATER SYSTEMrFREATING Dau Rueipt#
zz Applicant
C) NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,W. TOTAL:
r (4 become subject m the Workers Compensation provision of the labor Code,you must
� ; forthwith comply with such previsions or this permit shall be deemed revoked.. BUILDING FEE a/x1I
Ik1 [] CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby affirm tm them is a construction lending agency for Ne performance of
O TOTAL: ELECTRIC FEE
U
the work for which this Permit is issued(Sec.3(19].Civ.C.)
Lenders Name
u-' lenders Address QTY, _. -MECHANICAL PERMIT FEE PLUMBING FEE
C) LU1 certify that 1 have read this application rend state that Ne above information is
[y. correct.l agree to comply with allcity and county ordinances and atom laws mining to PERMIT ISSUANCE MECHANICALFEE
t^ building construction,and hereby authasiee repreaenutivesof Niscity former upon Ne - CONSTRUCTIONTAX
[� Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(Wr)agree to save,indemnify and keep harmless the City of Cupertino against
liabiIties,judgments stsando. ase.whichmoy in my roeaga]nnsaid City AIR HANDLING UNIT TO 10,000 CFM)
canxquerusa ting of Nis I
AIR HANDLING UNIT(OVER 10,001 CFM)
of pplicurt/Cmmcmr Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS LSDISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicantmr ino Mae bupal Codr.Chaper9,,ant alone or handle Health and Safety
HEATING UNIT(OVM 100,000 BTU) TOTAL:
as JefincJ by the Cupertino Municipal Cnde.Chapter 9.12,and the Health and Snfmy
Code,Section 25532(a)1 VENTILATION PAN(SINGLE RPSHE
❑Yes ❑Na
\ BOILER-COMP(3HP OR 100,000 BTU) ®ISSppUAN D DATE
ha.MWill Nevpylicmtarfmurtbuildingaxcupmtuseequipmcntodevittswhichemit • Py I D
.an conumivnts as defined by she Boy Ara An Quality Management ROLLER-COMP(OVER 100,000 BTU) oQ 1�
�timricf] ❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.IT.
P Fj O N��
1 have read the hnsrdcus materials requirements undo Cmpler 6.95 of the /sty# J
California Heald&Safety Code,Sections 25505,25533 and 255]4. 1 understood that VI I J ter
if the building does oaf currently have a tenant,that it is my responsibility m notify the �U�Cff 1
tccup to of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorised agent Due TOTAL: ISSUED BY:
OFFICE