25220 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO LD1 LL RUCAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. A C n O
B
111111.DINGPROJFCTIDF.N'TIFICATIOry L J G
UILDINGA DR 'S: ` SANITARY NO. APPLICA'OONSUBMITTALDATE
1 11` UNIT# LOT Ji
E S N M P 'S N ONTR E: 1
N/C CONTROL#
Cd TECT/ENGI F.ER: LI N D S ❑
CONTACT: PHONE-
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11
El A
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFMIAL JOB DESCRIPTION
OtyZ Iberebyafirm that lamliccnseA underprnvisioneofChupler9(commando,with
gWC see..hidnrce�dlef(ectvisiin3 ofd eBusiness and ofession•C d+ dmylicenee lx io PANELS
F,ZY1 Ucan.' IlP T03W AMPS
rn¢y Dae Comraztor 201-10(d)AMPS
ZOUK ARCIIITLCFS DECLARATION OVER His)AMPS SQ.PT.FLOOR AREA b/SQ.FT.
POO p 1 understand my plans shell heated es public records.
ani; SIGNS ELECTRICAL r
, Lieenxd Professional� _ l V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC ! i !�, m ® 0 N
�a F, I hereby uIII,that 1 am exempt from the Comment's License Law for the
3�m following reason. Scelion 7031.5,Business and Professions Code:Any city or county TEMP.MET ER OR POLE INST. 11� I�
rn which requires a perom m swa
con ,alley.improve,demm r an
olish, repair soman. tl
f }� primo,its issuance.A.requires lheapplicanlfar such penniOo Rleesigned statement POWER DEVICES
W �o Out he is licensed pursuant In the provisions of fl a Convector's License Law(Chapter
L o ' 9(commencing with Section 7000)of Division 3 ofthe Basinessand Professions Cade) SWIMMING POOL ELECTRIC TE LUAt'I N
_y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-1•IXTURES
JZZ} Section 7031.5 by any applicant for a permit subjects Ne applicantto a civil penalty of
� G nut more than five hundred dollars(SSOa).
❑ I,nownerofthepmpeny,ormyemployemwithwagesusthcirsolecompensation, NEW RESNIiNTIpI.F.LECfit _SQ.FT. STORIES TYPE CONSTRUCTION
^y3� will dnlhe wod,and the structure isnot imardedmoffered formle(Sec.]044.Business
and Professions Code:The Contractor'a License Law does not apply to an owner of
property whabuildsorimprovestherton,andwhodoessuchwork himselforthroughhis
"weemployeas,provideal thatsuchimprovementemenot immrudedmoffered formic.if, OCC.GROUP RFS.UNITS
however,the buildingm improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the handed of proving that he did not build or improve for purpose of
❑ Las ownaofthepmpmy,ameaclusivtlycomnetingwiNBcensed condnnorsm QTY. PLUMBING PERMIT FEE II.OGD'GDNE APN
answer the project(Ser.7044,Business.and Professions Code:)The Contactors
License Lawdoa notapply manowoerofpmpeny whobuildsorimpowasthcreon,and PERMIT ISSUANCE
who contracts for such projects with it convactons)licensed pursuant India Connector's ALTER-DRAIN&VGNT-WAT13R(EA
License Law. ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason OUTSIDE
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Date DRAINS-MOORROOFAREACONDRECF.IPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y.
I hertby affirm tM1alhave acmificate of consent to selLinsure,ora cenifcaeaf FIXTURES-PER TRAP RECEIPT#
mkeri Compcnmtion lnsunmecor o cmified copy 0aeof(SaJgOo,Lab C.)which PARK FEE Y N
raven elle to r 1ECEIPT#
GAS-EA.SYSTEM- INC.INC4 OUTLETS BUILDING DIVISION FEES
Policy M
Compact^ )Cenifecopy is hereby burnishedGAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is Mail with the city inspection division. GREASRnNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Dila section need dol be completed if the permit is foronehundraddollare(S100) SEWER-SANITARY-STORM EA.200 p. ENERGY FEE
orless.)
I cmify Nal iodate perfowanaof Ne work for which this permit is iaxued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers" PAID
Compensation Laws of Califomia. Dam WATER SYSTEM(TRFATING Dade Receipt It
Q z Applicant
z0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW REST DENTIAL PLMB. SQ,FT. TOTAL:
ry become sobjmuo the Wmom,Compensation provision f.ha labor Cadayau nun BUILDING IEE
a ; forthwith comply with such previsions or this pewit shall ba deemed revoked.
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 nearby affirm that there is a construction lending agency for Ne performance of
U O TOTAL: ELECTRIC FEE
the work for which this permit is issued(Sec.309],Civ.C.)
Lanai Nameres
0 � Lender's Adds QTY. MECHANICAL PERMIT IEE PLUMBING PEE
1 certify that I have read this application and state that the above information is MECIIANICALFEE '6. corneal,l agree to comply with all city and county ordinances and stale laws relating to PERMITISSUANCE
�•' building cooswetion.andhereby madv ire mprtsenativesofthisciry menta upon the CONSTRUCTION TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agcre to save,indemnify end keep M1urmless the City of Cupertino againt
liahiliti s,I dgmenlx,co sonde hich may in any way accrue against said City AIR HANDLING UNIT(TO 10'"CITE)
in con ce INe gr nti Nia t. AIR HANDLING UNIT(OVER I0,000 Cr
arymrme if A,pI emVCmarseleff Date EXHAUST HOOD(W/DUCU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt#
Will theapplicantmfiance building acupam store or handle harmdous material HEATING UNIT(OVER 100,000 RTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)]
El Yes ❑No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will Neapplicant armada buildi.gmcupmtumequipmentordevicawhichemil BOILER-COMP(3HPOR 10,000 BTU)
ezardoes air coatamincnts as defined by the Bay Amen Air Quality Management BOILER-COMP(OVER 100,000 BTU)
imi'l?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.Fr. pp
1 have read the haurd
aus materials requirements under Chapter 6.95 of the t- Ali)
Celifomia Health&Safety Code,Sections]5505,25533 and 25534. I understand Nat
I f l4buil p
atenithat it ismy responsibility to pacify the 1��� #�
upl n n m' usd be ma prior to issuance of a Cenificateof X� du /2 -NS43lI 00 Date ISSUED HN
oFRUE-