25028 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO tl -KILEC PRICAI PERMITNO. NJ cC� -/f/�� H
APPLICATION/PERMIT PLUMBING-MECHANICAWALNL.
BUILDING DIVISION UG PROJECT IDENTIFICATION 2 V O L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
S2ON\�1 I UNIT. LOT#
OWNER$NAME: . PHONE: COfiT Cf 'S NAME: �� LIC NO:
ll_ N NIC CONTROL#
\ RCHITECT/ENGINEER: LIC NO: ADDRESS:Ylt I v4AsJ ❑
'qW'ONTACT: PHONE: QTY] ELECTRIC PERMIT FEE BUILDING PERMIT INFO
L 1 N 2 52—S--7-70 PERMIT ISSUANCE BLDG ELECT' PLUMB MECH
If El El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DP.SCRIPDON
mwz Iherchyaffumthatt[ mlicenudunderpmvisionsofChapler9(commencingwilh
ttra��00 Section]000)af Division3 ofthe Bminess and Profeuions Code,and mylicrnuis in PANELS
y� full force and effect. UP TO 200AMP$ not
Fz Limnse Cims Lic.N
wF<m Data Contractor 201- AMPS ZO SQ.FT.FLOOR AREA S/SQ.Ff.
yZ ARCHITECTS DECLARATION OV IIXp MP
OZ C I undemund my plans shall be used v public mcoNa.
�rn .la4l SIG L'L
gCY'w6 License)Profeasionvl
OWNER-BUILDER DECLARATION fflIAI. RCU LSC.
W O:U I hereby mm�n that I am exempt from the Contractor'sns Co License Lew for the
W[34 which following reason.(Section constru Business and improve,
Code:Any city or county 'I' P.ME7ER OR POLE INST.
f� which requirexu permiuo construct,ulm'Simprme,demnlieh,or repair any sauaure
�f patheis ceased pintorttoresthnovidicmtl'the Comerc.Lierms LaJ anmment POWER DEVICES
p p 9(c he is license)pursuant to the provisions of the the Business
Liceme Law(Chapter
0.xp�• 9(mmmencing with Section]OBO)of Di on3ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATIOJ4_
W_w or the,he is exempt herefrom aero the basis for di tilleged exemption.Any,mbadonof O `0�
tZQ applicant Section 7031.5 by my applicant for a permit subjects the applicano a civil penalty of OUTLETS-SWITCHES-FIXTURES
SartA not more than fivehundmd dollars($500). NEW ID
❑ I,asowncrofNc Properly,mmyemployeeswithwegeseahcirwlecampensation. STORIES TYPECONSTRUCHON
y3.. will do he work,and lhesuudumis not insendcdaroffcred forsale(Sec.7044,Business •
and Professions Code:The Communes License law does not apply to an owner of
property who builds orimpmeas dereon.and winches such woo himselforthmughhis OCC.GROUP RFS.UNITS
sen employees,provides that such improveraems am not intended reoffered forsate.If. com
how egthe building or improvement issold within one yearofcamphomin,theowner.
builder will have the burden of proving that he did not build or improve for purpose of
s lo.).
❑ 1,as owneroftheProperly,am exclusively contracting wi0 licensed contracers to QTY. LUMBINGP. T FEE FLOODZONE APN
wnsnud the project(Sm.7044,Business and Professions Code:)The Contractor's PERMII'ISSUANCI?
License Lawdoes not apply m an ownerofproperty,who huildsorimprovesthemen,and
whocomrads fmaueh projects with acontracmr(s)licensed punumtto the Customers pLTCR-D0.AIN&VENT-WATER(EA)
License law. FEESUMMARY
❑ Tam exempt under Sec. B&P C for this mason OUTSIDE riirc-
I
RACK FLOW PRCTTCT.DEVICE SANITARY Y N
Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,CONO. SCHOOLTAX Y N
❑ Thffim
ereby ah that l have a cenm w
iDcaofconnto sebGce
insue,or a rtficam of RECEIPI'N
lnsor
mann'Compensation mancea rectified copy the00
oud(See.38 ,Lab CJ which R%TURES-PER TRAP PARK FEE Y N
covers all runin,m's under this permit. GAS-BA.SYSTEM.I INC.4 OUTLETS RECEIPT'N
Policy N BUILDING DIVISION FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenifiecimpyishmebyfcnishW.
❑ CenifieJ copy ie filed with rhe city inspection diviainn GRRASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP SOILS FEE
COMPENSATION INSURANCE
(This nectimn need nor be completed ifthe permit is fa mahundamdollen(SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or leas.)
I certify that in the perfomhmwe ofthe work for which this permit is issued,I shell WATER HEATER W/VENT/ELECTR
not employ my Person in any manner w as in become subject to do,Worker% PAID
Compoinukalawemf Califix.m. Dale WATERSYSTE14/1'REATING Data Receipt
p Z Applicant
Z 0 NOTICE TO APPLICANT:Hafer making this CeniBcatoof Exemption,you should NEW RESIDENTIAL PLMB. SQ.ff. TOTAL:
r4 become subject to the Worsts Compenwtion,wisiom ofthe labor Code,you must
C4 7 Forthwith comply with such Provisions or This permit shall he deemed awaked. BUILDING FEE
W O CONSTRUCTION LENDING AGENCY SEISMIC FEB
G✓ I he eby offrm that hem is a construction lending agency for the perfonnmce of •1'Ol•pL: ELECTRIC FEE
the work for which this permit is issued(Sec.3097,Civ.C.)
4T. t.y Lender's Name
U Tante,'.Address QTY. MECHANICAL PERMIT FRE PLUMBING FEE
U I certify that I have read this application and state that the above information is
W correct.I ugrm to comply with all city and county ordinances and stale laws relating to PERMIT ISSUANCE MECHANICALFEE
bui lding construction,and hereby authorize represemulives of this city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
C (Wfients.
indemnify aM kmp harmless the City of Cupertino againstliebilitiecmuandex sea wInch.vy'n any we wcruevgatnat saidCity AIR HANDLING UNIT(TO IO,g10 CFM)
Incoitieosis gramind tNs per
AIR HANDLING UNIT(OVER 10.000 CFM)
-a
APPlicanUComrador Dam EXHAUST HOOD(WIDUC)
mm
to ) j
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 10,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazvdons material HEATING UNIT(OVER 100,1100 BTII) T L:
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Stet 25532(a)P
Yes 13 No VENTILATION FAN(SINGLE REBID)
Cl❑
Will lh<upplicnnlorfuwrem m
buildingoccupnusceyuipmeardeviccs whichemBOILER-COMP(3HP OR 10,000 BTU)
it ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0011 BTU) W Y
District]
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IT.
I have nod the hmardaus matelots haparemenb under Chapter 6.95 of she up 29199
Culifomia I lmhh&SafetyCade,Stations 8505,25533 and 25534. I undersand that Cp r /
ifthebuitdingdoesnm cumentlyltmea tenant,that it is my responsibility certify she Ur (:urrT�
occupant of the requirements which must he mem prior to issuance of a Cer ificme of
Occupancy.
Owneror maintained agent Date TOTAL: ISSUED BY: V/✓yrs/Ifs!