25021 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' - "" PERMITNO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1
BUILDING PROJECT IDENTIF'ICA'TION
BUILDING ADDRESS:� SANITARY NO. APPLICAATXIONSUBMITTALDAE
2� V W y /, �/• " UNIT# LOT is
OW MEPHONE: C RACE 'SNA
NIC CONTROLp
RCIHTHCDENGINEER: LIC NO: AiESS:
'ONTACT: PHONE: Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I herels affirm Nat lam liceasedtunim p ( gwidt JOVDESC$&ION
❑yz y provisions of Che ter9 commando
a00 Section]Oml of Division 3aif the Basin ��y/¢��\1�� it license is in PANELS
�Z— fu arca nnJ annex Lic.# `� "� UPT02MAMPS
no Q Y le Conmclm 201-IOW AMPS
ZOyz se ARCHITECTS DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1 understand my plans shall be used u public records.
License)PSIGNS ELECTRICAL
5�dd rofessional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
u 3 tL u 1 hereby offino that I and exempt fmm the Convutor's License Law has the
F Oran following reason.(Section]031.5,Business and Professions Code:Any city wcounry TEMP.METER OR POLE INST.
y J which reclaims a permit to construct,alter,improve,demolish,or repair any structure
.n�7 prior to its issuame.dso requires the applicant for such Permit o file a signed statement POWER DEVI
Q p that he is licensed pursumt to the provisions of the Contractor's Lic<nx Lew(Chapter
L �' 9(cnmmcncing with Semion]OW)of Dlvision3of the Business and Professions Code) SWIMMING LELECTRICx I— VALUATION
as or that he is exempt therefrom and the basis for alleged exemption.Any violation of OUTLETS --IX-
tZ
Y Section by any applicant fmpermit..him.peraubjm.the applicam ma civil penalty of
nQ not more than five hundred dollars(S5W).
O
ro ❑ 1,asownerofthepro any,ormyemployemwithwagesastheirxlecompemation, NEW IDENTI IR S STORIES TYPE CONSTRUCTION
yB-2 will dothewurk,and the suvctumis not intendedoroffered nmsale(Sec.]0,14,Business
and Professions Code 'no Contractors License Law does not apply to an owner of
properywhobuildsorimpruvea thereogand whodaes such workhimselforthroughhis OCC.GROUP RES.UNITS
oweemploynex.provideddial such improvemenu arc not i m ended or offered for sd e.If,
however,the building orimprovemeat issold withinome yearofcompletion,theowner- TOTAL:
builder will have the burden of proving thin he did not build m ry
improve for puose of
sale.).
❑ I,nsowneroDbepropeny,mnexcw.ivelymmnctingwhlmticensedcmtmmorsu QTY. PLUMBING PERMIT PEE FLOODZONII APN
onsnacl the project(Sec.](N4,Business and Professions Code)The Cmmntctor's
Licenu law J,exam apply toanownerofpmp aywhubuildsorimproves Mention,add PERMITISSUANCE
whocontnctsforsuchpmjauwiNaconuanor(x)licenudpunueitoft Convector's ALTER FEE SUMMARY
License Law. (EA)
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUISI FEES
SANITARY YN
\ Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihemby a(f that l have a certificate ofconunrto self-insure,or.cenificate of Fl%TURES-PER TRAP RECEIPT Is
Workcn'Caimpensmion lmunnremecenified copy thermf(Sec.38W,Leb C.)which PARK FEE YN
covers all employee's undenhi,permit GAS-EA.SYSTEM-1 INCA OUTLETS RECEIPTp
Policy# BUILDING DIVISION FEES
Company FE
GAS-EA.SYSTEM-OVER 4(PA) PLANCHECK E
ElCertified copy is nearby famished.
❑ Cmified copy is filed with the dry inepec6ondivision. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section median becomplmed lithe permit is nature hundred dollars($100) SEWER-SANITARY-STORM II.2WFT. ENERGY FEE
or less.)
I cenify that in me perf...f the work for which this permit is laved,l shillT/
WATER HEATER W/VENELECfR
nm employ any person in any mammy ao as in become subject to the Wmkeri PAID
Compensutionlawsof Califomia. Dam WATER SYSTF.M/TEEATING Dam Receipt#
O z Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,z .. g s Cod you,youshould
mind NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
.�-, become subject a the Workers Compcnx his Permit
of the Iabm Code,you must
>
forthwith comply with such Provisions or this permit shall be deemed revoked. BUILDING FEE
GLI Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
z I hereby affirm that there iso construction lending agency fair the perfnnnunceof
L) O the work for which this Permit is issued(Sm.31097,Civ.C.) TOTAL: ELECTRIC FEEu.
Lenders theme
0 LeaPLUMBING FEE
I c
Irnd Address QTY, MECHANICAL PERMIT FEF.
certify that 1 have read this application and cute that the above information is
bonding Iagree mcomply
and hershymoyavd coumyntativnasand some laws
rupngu PERMIT ISSUANCE MECHANICAL FEF.
E-' z
building construction and representatives of thio cirymemer upon the CONSTRUCI'IONTAX
U z above- ironed property far inspection purpous. ALTER OR ADD TO MECH.
14
c ince to save,indemnify and kmp harmless the City of Cupertino against
liabil i )mdgmenr.cosu andexpenses which may in any way accrue agdn..said City AIR HANDU NO UNIT(TO 10,000 CFM)
is c oerm,of the gaming of this pe
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanVComrxmr Dam EXHAUST HOOD(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IdKI"BTU) Dam RmeiptX
Will the applicant or future building occupant store or handle hanordaus materiel HEATING UNIT(OVER IW,00(1 BTU) T
as defined by the Caperton Municipal Code,Chupmr 9.12,and the I leahh and Safety
Code,Second 25532(a)1
❑Ya 13 No VENTILATION PAN(SINGLE RFSID)
Will thea licantorfuture building BOILER-COME LIHP OR IW,000 BTU)
ISSUANCE DATE
pp he Bay Area Air mdevi Mar ichcmit
hezardaua nit contaminants m defined by the Bay Area Air Quality Mmegemem
Distinct? BOILER-COMP(OVER 1OLOM BTU)1:1Yes Els1�No NEW RESIDENTIAL MECH. SQ.PT. Y XA t
I have read the hez dous materials requirements under Chapter 6.95 of the �
Califoria Health&Sufery Cade,Sabre.25505,25533 and 25534. 1 undenund that
if the building does not currently have a tenant,that it is my responsibility an ��
notify the �9 r
occupum of the requirements which must he mm prior to issunnee of a Cenifwte of
Occupancy. Orr
Owner or authorired agent Date TOTAL: ISSUED BY: .