25787 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITU'OF CUPEPLUMBING MECHANICAL
PERMIT NO..
BUILDING DIVISION
sloN APPLICATION/PERMIT
BUILDING PROJECT IDEN'fiFIf,AT'ION 25787
BUILDING ADDRESS:
1 //j SANITARY NO, APPLICATTONSUBMITfALDATE
s^ k--.K UNIT# LOT# I.I�I{/ja�,\
O 'RS NAME: ON ' .� ONTR R'S NAME: LIC NO: VVV r 6(/
Inn, Gil Ei� NIC CONTROL#
.ARCHI CT/E GI E . LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
�7�{I„Q✓ BLDG PLUMB MECH
PERMIT NCE ❑ISSUA
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTTAL
mwz Ihereby affirmthat l amlicensed underprovisions of Chapter9(commencing with JOB DESCRIPTION
;W00 WUSection e f Division 3 of the Business and Professions Code,and my license is m PANELS
K V F full forcea emnud effete
Qz Vjzl License Claes IAc.# UP TO 200 AMPS
y=y Date Connector. 201-1000 AMPS _
oz-np
ARCHITECTS DECLARATION OVER 1"AMPS �S F�.F®R'A, $/SQ.
t-, I undernanJ my plans shall be used DECLARATION
records.
y ; SIGNS ELECTRICAL
��dd2 LlcenYed Professional
�C U mr
OWNER_
- emBUILDERCoATION SPECIAL CIRCUIDMISC.
O F F Ihereby efRThe[1 em expt from.the the Comramors License Law Be Ne
31i+m following mason.(Section 9031. Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
❑I"I'J which requires a n cels.re caramel,alter,improve,demolish,or repair anymassee e
CAC'�a� prionm its issuance,also requires the applicant foreuch permit file aligned statement POWER DEVICES
W G pa that he is licensed pursuant to the provisions of the Cmntracmts License Law(Chapter
4 e2 9(commencing with Section 9008)of Division 3 at the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
❑rte or that he is exempt therefrom and the basis fortheelcaud exemption.Anyviolation of
Smrion]031.5 by onyapplicare far a permit subjects the applirmtto a civil penalty of OUTLET'S-SWITCHES-FIXTURES
^� not more than five hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ.FT.
K� ❑ Lthewrk,adteestructumisntimandeeswiNwagesasthei(ec.compensation, STORIES TYPE CONSTRUCTION
a will N fework,and the he Cmuienotintenenseed Law
does net apply
1.on Business
and Professions Code: pr ve,th ant's License Lew ch not apply to an owner of
properly who
esbuilds.,improves thereon,and who m nsuch work tended oroff fm through his
own employeesildinprog or imp eemeuch npis sold itsin neyearrofrmoffered mroclethems.If, OCC.URDU RES.UNITS
however,the building or improvement is sold within of build
of complve for th purpose
of T
builder will have the burden nfproving that he did not build m improve for purpose of
ante.).
❑ I,as ownerofthe property,amexelusively contracting with licensedcontractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
emoumt the project(See.9044.Business and Professions Code:)The Convaemr's
License Lawdoesnaepply loan ownerofpopery whobuiids orimpmves thereon,and PERMIT ISSUANCE
who sonnets far such projects with a conmemr(s)licensed pursuant to Be Contrmtols
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE tJTSID FEES
OwnerDate SANITARY Y N
RCEfPTq
WORKMANE
COMPENSATION DECLARATION DRAINS-FLOOR,BOOP,AREA,COND. i
SCHOOL TAX Y N
❑ Ihereby effm Nell have ecenificam of consem mself-insure,oracertifiwte of FIXTURES-PER TRAP RECEIPT#
Workers Compensmsmaivsurance mil. ified copy Hereof(Sa.3800,Leb CJ which PARK£EE Y N
covers all cmploYee's ander this pernil. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT p
Policy N BUILDING DIVISION FEES
Company GAS_EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified capY is hereby fumiehed.
❑ Cenificd copy is fled with the city impectian division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section neednotbe completed ifthe Permit is forone hundred doR=($100) SEWER-SANITARY-STORM EA.200FT. ENERGYFEE
a'le's.)
I certify that in the performance ofthe work for which this Permit is issued,I shall WATER HEATER WNFNT/ELECTR
not employ any person in any manna so as to became subject m the Workem'
PAID
z Compensation Lews of Celifomia. Data WATER SVSTEM/fREATING
Applicant Date Receipt#
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL,PLMB. SQ.FT. TOTAL:
Fqy (A hecome subject to the Workefs Comperuadon provisions ofthe Labor Code,you must
a. . forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that them is a construction lending agency for the performance of
(, O the work far which Ms permit is issued(Sec.3091,Civ.C.) TOTAL: ELECTRIC PEE
LTw .-i lender's Name
ULenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LII I certify that 1 have read this application and state that the above information is
comet.I agree to comply with all city and county ordinances and state laws misting In MECHANICAL FEF.PERMIT ISSUANCE /�
Lei building construction,and hereby authorize represenmvesofthis city to enter upon the
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
F7 (We)agree to save,indemnify and kmp harniess the City of Cupertino against
liabilities,judgmen(s,costs and expenses which may in any way seems mains?said City AIR HANDLING UNIT ITO 10,000 CFM)
fth gran' g f mi /p
V tierce a AIR HANDLING UNIT(OVER 10,000 CFM)
Srgnmure of Applirmd/Contracmr Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dem Receipt#
Will the applicant or forum building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)P
❑Yes ❑No VENTILATION PAN(SINGLF.RESID)
ISSUANCE DATE
Will the a Ilcantor futurebuildln oats amuse BOILBR-COMP(3HPOR 100,000 BTU) -
pp g p Area Air Quality Management
haztrict? air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OVER 100,0011 BTU qq
DlsulcLT ( ) LW
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.
I have read the hazardous materials requiremems under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I undemmad that
ifthe building does not currently have a tenant,that it is my responsibility to notify the CITY l)t CU 't
.cap.,of the requirements which most be met private issuance of a Cec ift a.w of
Occupancy. _
Onanamauthonzedagent - Date TO L. ISSUED BY:
OFFICE