25662 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOH171Ia, ,.E,TRI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25662
1 5 VM VM L r/�/� /1
BUILDING DIVISION CT
BUILDING PROJE 'IDENTIFICATION L
BUILDING ADDRESS: �I wA�U SANITARY NO. APPLICATION SUBMITALDATE
y/` V NITp LOT 162�-q3
S NAME: PHONE: 'RACTOR'S ♦ O.
.�/C CONIROLh
R II'I I 'WEER: LIC NO: Sg:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUME MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPI'I(IN
gC)y Ib7000)affirm tial am licen.aAunderprovisiona of CM1epmr9(commencingwith ��)S� � �awp
0.100 $Ccll(m7IX10)mf DIY 3mfthc Bmincss and Pofcssimnx Cr Je,u(commenci giv in PANELS
�\V
y F full force and effect _
I.ic.pA/�S
V G/ �, UP TO 200 AMPS
�Zty Liccnm Class �—
m6e. Uate Cnnlrecmr 201-1000 AMPS
F so
K ARCHITECTS DECLARATION SG.17.FLOOR AREA S/SQ.FT.
C)Z_ l understand my plans shall be used ss public records. OVE0.101W AMP,
�,„F W SIGNS ELECTRICAL
Licensed Professional
�Yd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt from the Contractors License Law for the
LL3LLy IiJlowingreason.(Section 70315,Basines,inlPme,,icus Core:Any city or county l'EMP.MFT ER OR POLE;INST.
which requires a permit to construct,alter,improve.demolish,or repair any structure
�WNto its issuance.also re es the applicant for such Int fileosi ed smmmrnt POWER DEVICES
prier 41.t pp nchi gn
y)Ca0p that9(v heislicensedpursuantmthepmvibubof thethe BuslorsmallseLaw(sCurler SWIMMING POOL ELECTRIC
dao 9(mmmeis exemitM1 therefrom
Division Sof the Business ono,Any violation
na Cad e) VALU
or that he is exempt and the hosts for the thicdcxcmption.Anyvio Ntyof
F-ZQ
Section 7031.5 by any applicant for a permit subjecu tM1e applicant to ecivil permlry of Ol1TLET5-SWITCHES-FIXTURES
ESQ ml more than fisc hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCr10N
WI= ❑ I,mownerofUepmKrty.ormyemploceswithwagesutheirsolecompensation,
a3— will dothe wnrk,andma structure is not intended oroffered for sale(Sec.0004,Business
and Professions Code:The Contractors I.ke ow Law does not apply to not owner of
propcny who builds or improves thereon,andwhodoex.meh work himselforthrough his
anployces,provided than such Improvements:ucnot intended oroffered fonale.lf, OCC.GROUP REX UNITS
however,the building or improvement is sold within one yearofcompletion,themwner- TOl'AL
builder will have the burden of Proving that he did not build or improve for purpose of
`ale')" TY. PLUMBING PERMIT FEE FLOOD LONE. APS!
I,asowneroflhepropeny,amexclusivelycontmetingwithlicensedcontracmmto Q
construct the project(Sec.7004.Business and Prebendaries CW_0 The Connote are a
License Lawdoes not applyto an ownerofpmWdywho builds or improves thereon,and PERMIT ISSUANCE
who contracts four such projects with memaractorts)licensed putsuam to the Cmnhacmre ALTER-DRAIN&VPNT-WATFA(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason BACK OW '1p..C�IAVI,a,rr�� fpI t I OUTSIDE FEES
7. a ,`.1 !I SANITARY YN
Owner Date DRAINS-FL R,ROOF,AREA,COND I RBCEII.1'M
WORKMAN COMPENSATION DECLARATION O 0 t SCHOOh'I'AX YN
❑ IbembyaffimihatlhavcacenibcateofconumtoselGinsure,nra¢nifcatmf FlXTURES-P AE Y V� b V RECEIPI'p
Workers'Compensation Insurance ora certified copy thercof(See.3800,Lab C.)which PARK FEE Y N
covers all em to a's under this permit. RECEIPT'p
D Y GAS- .SYSTE I N O BUILDMM1CVISION FEES
Policy p
Company GAS- EM,OVER 477) ---- --- -P7INCHECK FEE
❑ Certified copy is hereby famished.
❑ CmifieJ copy is flet with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FlB?
CERTIFICA'IT01;EXEMPTION FROM WORKERS' GREASETRAP SOILS FEIN
COMPENSATION INSURANCE
(This action need nil In completed iiia permit is formic hundred dollars($IN) SEWER-SANITARY-STORM EA.20014. ENERGY FRIT
or less.)
I cenifythat in the perfmmanceof the work fm whichtbis permit is issued,Iahall WATER HEATER WNEN/ELECIR
not employ any pe.a in any manner so as m become subject to the Workers' PAID
Compensation Lawsmf Califomin. Date WATER SYSTEM/TREATING Date Rceet,at
OZ Applicant
z z NOTICE TO APPLICANT':If.after making this Certificate of Exemption,you should NEW RESI DENIAL FLMB, SQ,FT. TOTAL:
.a h hmemme subjectto the Worker's Compensation provision,of the LaMsr Code,you..at
F-' ? forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE p.
C4 1
W
0.. [� CONSTRUCTION LENDING AGENCY SEISMIC PEii �
7 Z I hereby affirm that here is a conshuction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for whichthi,permit is issued(See 3(197,Civ.C.)
Lenders Name PLUMBING FEE
U" 'r' Lender's Address QTY. MECHANICAL PERMIT FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE
)" W correct.l agree to comply with all city andordirracc andstate laws relating to PERMIT ISSUANCE
f•" "5 build4�',and hereby amhoti represgilativesof thisOlymenterupomhe CONSTRUCTION TAX
U Z abovperty for inspec nIn
ALTER OR ADD*10 MF.CIL
,indenmi and kecp�rannlnys @e City of Cupeninn vgulnst
liabia.,is and penses which may in any way accrue again stsaid City AIR HANDLING UNIT('TO FLOW CFM)
can fthis permit.
/ AIR HANDLING UNIT(OVER 10,000 CFM)
ag UComfoctor Dam EXHAUST FOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO FAIL o BTU) Date Receipt h
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.0010 BTU) T
as defined by the Cupertino Municipal Cale.Chapter 9.12,sad the Health and Safety
Codc,Section 25532(a)7
❑Yes 11 No VENTILATION PAN(SINOLERESID)
ISSUANCE DATE
Will theupplicam or future buildingoecupant useequipment ordeviceswhich emit BOILER-COMP(31 IF OR I W."BTU)
hazandone air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP(OVER 100,000 BTU) Rgyy (p� pk
Jistrictl P A 9 y
❑Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have mad the hmmdous materials requirements under Chapter understand
of the ®6T 21 19
California have
Hcabh&Safety Code,Sanious 25505.requirements
and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the }�y
Ooccupant of the requirements which must be mel prior to Issuance of a CerriGnrm of C�
ccupancy. V I U
Owner or militarized agent Date TOTAL: ISSUED BY:
OFFICE