25055 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONO APPLICATION/PERMIT PLUMBING-MECHANICAL PERMIT NO. O
BUILDING DIVISION BUILDING PROJECT IDENTIFICA'1']ON
55
BUILDING ADDRES : / - SANITARY NO. APPLICATIONSUBM(ITALDAIE
n) it CN021 DN » OT» S� o
.RS NAME: PH 2 CO TOR' AM : LIC N
N/C CONTROL»
IP'I'Q
f ITELT ESS: 2�j
O ACT:
CITY. ; . ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE M El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL srY )OB DESCRIPTION
pmz Ihereby affirmthal l stalicensed under provisiomofChaper9(courmencingwida
x100C Sectioni ian3of Ne Businmaand Rofea+iosCodendlue is in PANELS /NFJO0lect //J/1Gz WDreC UPTO200AMPS
vFi6y DGOnlraClmr 201.1000 AMPS
,ZOyZ ARCNRF.CTS DECLARATION OVER10t AMPS SQ.FT.FLUOR AREA VSQ.FT.
O z•• I undersand my plans shall be used m public records.
Mod SIGNS ELECTRICAL
g,Y, ,,) Licensed Professional
0: OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O d F Ihereby aRrm that I and eumpt from the Contract
&a License law for The
3
Eon following reason,Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
trJ H g which requires a permito commrcL wler,improve,tlemolish,or repair any swmure DEVICES
an
prior inamcucc,alsorequircstheapplicuntforsochpermittofile.signedsam
aent
Y q O Thal he is licensed pursuant to the provisions of the Contractors License law(Chapter
80 9(commencin,with Section7110B.I'Division 3ofthe Business and Prufessi...Code) SWIMMING POOL ELECTRIC VALUATION
Mo, or that he isexemPl therefrom and the basis forthe alleged exemption.Any sumnaan of OVfLEfS-SWITCH
4 Section 7031.5 by any applicant for a permit subjects the applicant in v civil Penalty of
not more than five hundred dollars($50(). NEW RFSIDFNTIAL
K ca ❑ I,asmwnerofthepmpay,ormyempl0y swithwegesmtheirsolecompcmafimn, RIES TYPE CONSTRUCTION
y will dothework,tend Ne suuctureisms intendedoraffered for mle(Sec.7 4.Bmin n
and Professions Code:The Contraor.Licrno law does not apply to an owner of
property whobuiWsorimpmoves lhereorand whodas such work hirromforthrough his GROUP RES.UNITS
employero
s,pvided that suc h improvemenu teenot i ntended or offeted for mile.If,
however,the building or improvement is sold within one yearofcompletion,the owner.
builder will have the burden of proving that he did not build or impose for purpose of
sole.).
❑ I,asownerof lM1e propmy,emeadusivdycanvacting with liamed wntracorsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onatruct the project(Sm.]094,Business and Rofessions Code:)The Co por,mas
License Lawdossnompply man ownerofpropeny whobuilds orimprovas thereon,and PERMIT ISSUANCE
whacmntracu forsuch pmjea with acontractor(s)Iiamcdpurauantothe Conme,am's ALTER TA FEE SUMMARY
License Law. IR )
❑ I am exempt under Sec. ,B&P C for this masa BACK FLOW PROTECT.DEVICE T
SANITARY Y E N
Owns Date DRAMS-FLOOR,ROOF,AREA,COND. RECEIPT»
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
I hereby affirm that l have v cenificme ofansent to self-insure,or a cenificate of FIXTURES-PER TRAP RECEIPT»
_ rkels'Cnmpemntion Insuranceor.cenifed copy thereof(See.3818,Lab C.)which PARK FEE Y N
us
en ml employees under this premix GAS-EA.SYSTEM-1 INCA OUTLETS RECEIPT»
Policy p BUILDING DIVISION FEES G
Company GAS-EA.SYSTEM-OVER 4BEAT PLANCHECK FEE 4 0
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF.TRAP SOILS FEF.
COMPENSATION INSURANCE
(This auction need not the,completed ifthe permit is forma hundred dollars(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
tuners.)
I certify that inthe porfmmance of use work for which thin permit is issued,I shall WATER HEATER W/VENT/ELECIR
net employ any person in any maser o as an become subject to Ne Workers PAID
Compensation L.wa Of Califomiv. Date WATER SYSTEM(fRFATING Date Keeiplp
0 z Applicant
70 NOTICE TO APPLICANT:If,ofterm.king this Certificate o(Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL: V
P y thns
became subject to e Workers Compensation provisions of Ne Labor Code,you muss n
Fa 7 forthwith amply with such Provisions in this permit shall be deerned revoked. BUILDING FEE r V
W
z CONSTRUCTION LENDING AGENCY SEISMIC EEE s �0
^a I hereby affum that hem is a construction lending agency for the perform.nce of
U0 the work for which this p und,is issued(Se.30)7,Civ.C) TOTAL: ELECTRIC FEE
u. [enders Name
0 lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify Nat 1 have read this application and sate that the above information is
1 romcl.lattice to comply wit all city and countymdianas andiate law.mlmingo PERMIT ISSUANCE MECHANICAL FEE
buildingconstsuc(ion,andhembyauthodzemprescnmtivesofthiscitywrnterup nthe CONSTRUCTION TAX
V z above-menny for inspection purpose. ALTER OR ADD TO MECH.
(We) gra m s ve,iMemnify and keep hertnlm the Ciry of pars a wet
liabilities, d expenses whichmayinany way accrue ag nstca' City AIR HANDLING UNIT(TO 10,11110 CFM)
in can of granum Ihispermit.
AIR HANDLING UNIT(OVER 10,000 CEM)
Signature pylic. ucconoctor a EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,W0 BTU) Data Receipt»
Will the applicant or future building occupont store or handle ha.ardom mamdw HEATING UNIT(OVER IOo000BN) -15
TOTAL:
as defined by the Cupertino Mmieip d Cade, ,
e,Chapter 9.12,and the Health and Safety t
Code.Section 25532(x)?
11 Yes ❑No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Will thea licamafuwm buildin ecu sutuu ui BOILER-COMP(311P OR 100,(10)BTU) D
pp g p W pmrntouality M.....man, P A
Dhimrdous sir cnntmninvms m defused by the Bay Area Air Quality Manngemem BOILER-COMP(OVER 100,000 BTU)
uWet?
❑Yes ❑No NEW RESIDENTIAL MECH.-SQ.IT.
I have read the hazardous materials requirements under Chapter 6.95 of the MAY I1993
California Health&Safety Code.Sections 25505,25533 and 25534.I understand Out
if the building does not currently have a tenant,that it is my responsibility in notify the Clft �r wren ulna
occupant of the requnamems which must be mel Prior to issuance of a Certificate of
Occupancy.
Owner or euthoriuw.gent Data TOTAL: ISSUED BY:
OFFICEd