25914 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO B HICAL PERMIT NO. '
APPLICATION/PERMIT PLUMBING-MECHANICAL 25914
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL
DATE
*7 phol Ang UNIT# LOTH
12"oATt PHONE: CONT CTOR' NAME: LIC NO:
I _ r` C 1C J N/C CONTROL#
ARCf11TECT/ENGINEER: LIC NO: A DRE I ❑
S
CONTACT: PHONE: IL 1913 PERMIT INFO
- QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE E] rw
LICENSED CONTRACTOR'S DECLARATION LITF- 1:1
pppL1ANCPS-RESIDENTIAL TOB DESCRIPTION
0
yz, I hereby affirm thml am licensed underpmOdonsof Chapler9(e mmencingwith
0r Section 0000)of Division 3 ol'ihe Business and Professions Code,and my license is to PANELS 1r
p(zp full force and effect.
6 License Class _ '� Lic.k� UP T0200 AMPS
ypvDa Date Contractor Oji✓ 201-1000AMPS
I-'ro z ARCHITECTS DECLARATTON f SQ.FT.FLO AREA $/SQ.FT.
Z O rn OVER 1000 AMPS
O2.^ 1 understood my plans shall be used as public records. -
�''J SIGNS ELECTRICAL
< G^�
Licensed Prohseicnal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ryry,,O a F I hereby affirm that I am exempt from the Contractor's License Law for the
do3 C following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
15 rn.] which requires a permit to construct,alter,improve,demolish,or repair any structure
ori
point.its issuance,alsomquires theappimant forsuch permit to fileasigned induced, POWER DEVICES
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter -
xo 9(commetring with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Iy�y or that he is exempt therefrom and the basis for the alleged exemption.Any violadoof
OUTLETS-SWITCHES-FIXTUR�S
4 Section]031.5 by any applicant for a permit subjects the applicant to a civil Penaltyf
M=more than five hundred dollars($500).
Q El1,asowneroftheproperty,ormyemployeeswithwagwastheirsolecompensadon, NEW RESID AL ELECIR' t r ISQ.FT. - STORIES TYPE CONSTRUCTION
G.3n will do the work,andthestrucome isaotimended ocofferedforsale(Sec.0044,Bulinus
and Professions Code:The Contractor's License Law does not apply 0 an owner of
property who buBdsorimprovesthereon,andwhodcessuchwork himselforthmugh his `
employees,provided Nat such improvememsarenolinlendedorofferedforsale.If, (OCC.GROUP -RES.UNITS
however,the buildingor improvement is sold within Meru ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,atnexclusivelycontracting with licensed contractors to QTY, PLUMBING PERMIT FEE FOOD_ZONE APN
construct the project(Sec.7DH,Business and Professions Cade:)The Contrectors .oD
License Law does not apply to a a owner ofproperty who builds or improves thereon,and PERMIT ISSUANCE
whocontracts forsuchavoccts wilhacontmcmr(s)licensed pursuant To The Customers ALTER PEE SUMMARY
License Law. (EA)
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUT D FEES
SANITARY Y N
Owner Dale DRAINS-FLOOR,ROOF,AREA,COND.- RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers'Co affirmthat lhave
rance orla compact copsent to y
thereof(Sec.
Lab C.)ate ofwhich RECEIPT'#
FIXTURES-PER TRAP r.
Workers'Cmployee'sndarthisermioenlBeO copy thereof(Sec.3g00,Lab C.)which - PARK FEE Y N
covers Policy#Ilemployee'sunder this permit, GAS-EA.SYSTEM] J TS RECEIPiq
s✓�'%" BUILDING DIVISION FEES
Company -faGAS-Ea .LEA) PLANCHECK FEE
❑ Certified copy Is hereby mished. i
❑ Certified copy is filed with the city inspection division. ORrIo ,KC WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 61.✓TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthepermit is foronehundred dellars($I00) SEWER-SANITARY-STORM EA.2110FT. ENERGY FEE
or less.)
I<ettify tha[in the performance of the work forwhich thio permit is issued,(shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so To become bject to the Workers' PAID
Compensation ICalifo Dnp Y/'-9 WATER SYSTEMiTRGTING
ryW�y t 3- [� De[e Receipt#
Q z Applicanty �.L%SLL
z7�+ � NOTICE TO APPLI oAork If,is toter making this C visions m of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
t� become subject m the Worker's Compensation provisions of the Labor Code,you mum
�i fonhwith comply wish such provisions or this permit shell be deemed revokM. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm That there is a commortion lending agency for thm
The Emf dMi,of - TOTAL: _O' ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name
C U Lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I certify Net I have read this application and state that the above information is
acontext.l agree to comply with all city east county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
rA 7 building construction,aadhereby authmies representatives ofthis city to enter upon the CONSTRUCTION TAX
V a above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.'
(We)agree to save,indemnify and keep harmless the City of Cupertino against /I
liabilities,judgments,costs and expenses which may in any way income against said City AIR HANDLING UNIT(TO 10,000 CFM) 7, • a0
in c f then
"tedo,of Bit pe it
onseypenceo y5�: AIR HANDLING UNIT(OVER 10,000 CFM)
Sn Aa[ure of` n'— 66 1 r{e- EXHAUST HOOD •1
g pp t/Conuactor b�
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0100 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL: •J
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(e)? VENTILATION FAN(SINGLE RESID)
11 Yes 11 No
ISSUANCE DATE
Willtheapplicanmrfumrebuildingoccupanluseequipmenlordevices whichemil BOILER-COME(3HP OR 100,000 BTU)
harardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I W,000 BTU) PAID
hod"?
t ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. FEB �� ����
I have renhazardous
d the materials Momentums under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a tenant,that it is my responsibility (�to notify the. ^I I Y Ur L urth 1114U
occupant of the requirements which must be met Prior To issuance of a Certificate of
Occupancy.
Owner or authorirod agent Data TOTAL: ISSUED BY:
OFFICE