25832 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO1 BOL JNG-ELMr AL PERMIT NO.
APPLICATION/PERMIT PLUMBINGID-MECHANICAL 25832
NUII,DING DIVISION BUILDING PROJECT EN'TIFICAI']ON
BUILDING ADDRESS: V SANITARY NO. APPLICATIONSUBMITTALDATE
/0370 / /09WICH AVE ,
UNIT# l.(;T#
OWNER N ME: ol .;HONE: CONTRACCI'1 R' NAM LIC NO: N/C CON'IROLa
ARC( TE Ai GINEER: LICNO: ADDRESS:-V N ❑
ICONTACT: PHONE: HUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDEN'1'IA1.
O=Z I hereby affirm that l am licensed underprovisionsufChepter9(comci
menng with
JOB DESCRIPTION
WOO_ Section]000)of Division Sof the Business and Professions Code,and my license is in PANELS
[[-- rml force dna erceet. f1
FC UkJ UP TO 2M AMPS VTv p
yly Date Class Co.,.#
,i=«
Date GOor 201-1(100 AMPS
Fye ARCHITECTS DECLAHAords. OVER 10(18 AMPS � SQ.FT.FLOG AREA S/SQ.pI'
OG 1 understand my Nana shall he oud as public regards. KK /'\ e�f�f(r
<y Mµ] SIGNS Ii1.CC'IRICAL ly-ll
W-yy-,j Llucnmd Professional
�yrEQ OWNER-BUILDER DECLARATION SPF.CIAI.CIRCUIT/MISC.
X O a U 1 hemby affirm that 1 oro m th
exempt froe Contractors License Law for the
W 3 LL on following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1_aOQ which inquires.permit remosract.til tiny...,demolish,me.siranystruaum
�WYS that he as licensed pursuant to the thevisios ofthe Co perniuo filLicense
La smtemem PoWF.H DEVICES
C 6O @m he is licensed pursuant to the provisions of the Contractor's Littnx law(Chane
aao� 1)(immmencing with Section 1000)ofidsmon 3ofthc Buxi^ersand Professions Code) SWIMMING POOL ELECTRIC VALUATION
W❑y Srthm h7031.5by any
yaplicnt for
the basiafmthects thedeaemption. civil elation
FJQ Section]Dour fi an od"d camrs($50rnit suhjectxthe npPlicanuoocivil penally of OUTLIdfS-SWITCHES-PIX'(UHIiS 11
rc than Bvc hunJmd Jolles ymrpI o
f9p NEW RI: ME ELECIR _SQ.FT. S'I'ORIE5 I'YYIi CONSTRUCI'ON
iCFo ernfdn sttmctumrsnwint dy oroffca fora le(Sm.7a ,,ammo,
3 will Jr sae work.andlhesW<tum isnot intendMornf(ered forsalelSa.]044,Business
and Professions Code:The Contractors License law docs not apply to an owner of
aaperty who builds or impmva thereon,and who does such work himselfor duough his
ownemployees,provided that suchimproveraems we not intendedmoffemd foraele.If, OCC.GROUP RFS.UNITS
however,file building or improvement is sold within one yearofecmpletion,the owner. TO
builder will have the burden of proving that he did not build or improve for purpose of
PLUMBING PERMIT FEE
aaI)et.1......er of the pmpenY.em exclusively contracting with licensed amtruclnrr On QTY. FLOOD ZONE MIN
athe projca(Sec.1044,Business and ssio
Profens Cade:)The Contractor's
Lmine icense Law doesmmapply to an owfc,.f,.,dy whobuildsorimproves damon.and PERMIT ISSUANCE ,
whoconima forauchpmjatawirhaconv tom s)liCenwdpuru=ttodte Commctors ALTER-DRAIN& T H 9 r� FEE SUMMARY
License Law.
❑ I aro exempt under Sec. ,B&P C for this mason BACK FLOW PRO .D CE � OUTSIDE Il: S
F\ i1 /) I - 7' SANY N
Owner Da `) d �I RECEIPI'p
te
DRAINS-PLOOR,R OF. OND.+
WORKMAN COMPENSA'f10N DECLARATION 11001.'1'A% Y N
❑ (hereby uflinn thalhaveaceni0cam of consent.self-insure,ur ocenifcac of MXTURES-PERT P RGCEIPI'Is
Wmkers'Compensmion lnsumncc ora certified copy thereof(Su.3R00,Lm C.)which '.E / Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 C.4 OUTLETS IPTO
. BUILDING
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEMOVER4(EA) PLANCHECK FEF,
❑ CenifieacoMishftehyfumished.
❑ Caddied copy is riled with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATGOF EXEMPTION FROM WORKERSGRF,ASETRAP SOILS PHE
COMPENSATION INSURANCE
(This scourn need not be completed ifthc permit is foronc hundred dollars D Up) SEWER-SANITARY-STORM BA.200FT. ENERGY Ilia
or leu.)
I ttoy that in the inmyanceater so as
fm become,subjecpermit o the Workers
WATER HEATER W/VENT/ELHCfR
not employ may wa rdf in any manner so as m biome subject m the Workers' PAID
Compcnmfion laws of Celifomia. Dine WATER SYSTEM/IRFATING Dam Receipt If
O z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RFSI DENTIAL PLMB. SQ,FT. TOTAL:
z become subject to the Worker's Compemaion provisions of the Labor Code,you must
Pothwith comply will,such pros-ons or perroullill be deemed revoked. BUILDING FEC
C. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them is a construction lending agency for fire performance of
U Z TOTAL: ELECTRIC FEE
O the work fm which lilts pennif is issued(gee.3091.Co.CJ
Lender's Name�- PLUMBING FEE F Isnder's Address QTY. MECHANICAL PERMIT FEF,
U I certify that 1 have read this application and slam that the above information is MECHANICAL PEE
cored.l agree In comply with all city andcourmy ordinances and slow laws relating to PERMIT ISSUANCE
F' OZibuilding construction.and hereby repreaematims of this city to c^mr main the CONSTRUCTION TAX
UZ Move-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,jid ms.cosmandeapens whichmayin unywayacemelf,una said City AIRIIANDLINGUNU(TOIO,"CFM)
in cont ofma gmming of AIR HANDLING UNIT(OVER t0JXp CFM)
le Sig urea pplicanV omracmr Dae EXHAUST (W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEAPING UNI'r(TO 1(10,0(00 BTU) Dam Receipt#
Will the applicant of future building occupum store or handle hazmJous material 'I'OI'AI
asdcfiladby the Cupertino Municipal Cole.Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTT)
Corte.Section 25532(a)]
El Yes ❑No VCNfI1.AT10N FAN(SINGLE R[SID)
ISSUANCE DATE
Will theapplicanturfmure building occupant use equipmemorde,miftwhichmat BOILER-COME CHP OR 100,000 BTU) yy p
• ardor,air comaminum,as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU) r .4 I
ricR
❑Yen 1:1 No NEW RESIDENTIAL MECH.—SQ.FT.
I" 1 hove read the hamNous materials mquimancms under Chapter 6.95 of the Occ 10 19
Iif the uil ing dos Safety Qde,Sections 25505.25533 mrd 25534. 1 u^dosm^a That
I
the building does not currently have a tenant.m.f it is ter rexlanaibaify to nadry the ClI Y G
eecupant of the mquirsmems which must be met prior to issuance of a Certificate of r VV�r�h�# �(
Ocsmarcy. �\ \ /��/./Ya/�/�N\,
Owner or aaNarieuJ agent Date TOTAL: ISSUED BY. V Vxae f k -
OFFICE