25625 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOHUI IAINU - hLhU I HIUAL PERMIT NO.
APPLICATION/PERMIT PLUMBING - MECHANICAL25625 n C
BUILDING DIVISION BUILDING PRO.IECT IDENTIFICATION J G J
ABUT ITECf/LNGINEER: /\ I ?
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ADDRESS:
❑
CONTACT: PHONE:
4
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QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELECT PLUMB MF.CH
❑ ❑ ❑
PERMIT ISSUANCE
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65100
LICENSED C TRACTOR'S DECLARATION
I hereby (firm that l am licensed undo [Chet 9(commencin with
re pm Profestu per eis
Section Softhe Business and Professions Code, and my license is in
APPLIANCES - RESIDENTIAL
]OB DESCRIPTION
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PANELS
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farm and fDivision
full farce lass eflBa.
License Class Lic.n
UP T02. AMPS
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Date Connector
ARCI IITEC'S DECLARATION
I understand my plans shall be used as public records.
201 - 1000 AMPS
SQ, IT, FLOOR AREA
S/SQ. Er.
OVER Il100 AMPS
SIGNS ELECTRICAL
Licensed Professional
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OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contratmr's License Law for the
following mason .(Section ]031.5, Business and Professions Code: Any city or county
which requires a permit to wnswct, alter, Improve, demolish, or repair any mundane
prior to its issuance, also requires the applicant for such permit to file a signed sustained,
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
nemg with Serum 90) of Division 3 of the Business and Professions Code)
9(comme.
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
9031.5 by any applicant for a permit subjects the applicant a civil penalty of
not more than five handrail dollars ($500).
❑ I, as ownerofthe progeny. or my employees with wages as their who compensation,
will do the work, and the strunurc is not intended or offered forsale(Sec. 9044, Business
and Profession Cute: The Contractor's License Law does not apply to an owner of
SPECIAL CIRCUTT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUA
�QO
5 ig TYPE CONSTRUCTION
OUTLETS - SWITCHES - FI R
- II
NEW RESIDENTIAL ELECTR BQ.FT.17
i
properly who builds or improves thereon, and who does such work himself or tbr0ugh his
on employees, provided that such lmproveesare not intended oroffemd forsale.If.
homm
wever, the building or improvement wield widuin nnc year ufmarpl lima, the nwne,
C OUP
RES. UNITS
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEB
sole.).
❑ I, as ownerofthepropeny,am exdusivelycontracting with licensed convacmrsm
FLOOD'
AVN
construct the project (See. 7044, Business and Professions Code:) The Contractor's
License Law docs not apply manownerofproperty whobuildsor improves Norden, and
PERMIT ISSUANCE
whocontrace, forsuch projects wish.contractm(s) licenced pursuant o the Contractor's
License Law.
ALTER -DRAIN&VENT-WATER EA
( )
PEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
RACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
Owner Date
DRAINS - Fl.00RROOFAREA.COND.
,,
RECEIPTp
WORKMAN COMPENSATION DECLARATION
❑ 1herebya(fnm that I have acenificateofeamseatto self-insure,ora certilicateof
Workers' Compensation Insurance or acenified copy theradf(Sec. 38., Lab C.) which
covers all employees under this permit
Policy M
SCHOOLTAX YN
RECEIPTp
FIXTURES - PER TRAP
PARKFEE Y N
RIVISIT p
GAS - EA. SYSTEM -I INCA OUTLETS
BUILUING DIVISION FEES
D
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cornified copy is hereby furnished.
GREASE/INDUSTRL WAS' TE INTERCEPTOR
GRADING FEE
❑ CenifiW copy is filed with Ne city inspemitun division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEF.
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20OFT,
ENERGY FEE
- ('Ibis action necdmabe complated if Nc pe—i,,s fortune hundred dollars ($100)
or less.)
I ccnify that in the performance ofthe work for which this pemtilia issued. i shall
not employ any person in any manner so as to become subject to the Workers
Compenmtou Lawsof Califamta. Dam
QZ Applicant
Z Z NOTICE TO APPLICANT: IL of rm king this certificate of Exemption, you should
WATER HEATER W/VENT/ELECTR
PAID
Date Receipt Is
WATER SYSTENVTREATING
NEW RESIDENTIAL PLMB. SQ. FT.
TOl'AL:
f" � becomesubject subjeco the Workers Compensation provisions of the Lehr Code, you must
�> forthwith comply with such provisions or this permit shall No deemed revoked.
CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a construction lending agency for the performance of
L) O the work for which this permit is issued (Sec. 3099, Civ. C.)
Lender's Name -PLUMBING
Lender's Address
V 1 certify that 1 have read this application and stale that the above information is
>, LTa correct. l agree to comply with all city and county ordinances andsmrt laws relating to
E" building construction, and hereby authorize representatives ofNiscity to enter upon the
Oshove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless Ne City of Cupertino against
Its ililie"Judggmenta, costs andexpenuswhich may in anyway accrue againstsaid City
nsctryer6c of tht gmntinB oil NLs t
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT PEE
FEE
PERMIT ISSUANCE
MECHANICAI. FEE
ALTER OR ADDTO MECH.
CONSTRUCTIONTAX
AIR HANDLING UNIT('TO 10,0(1() CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
PAID
.Ignuture of Appbcnt/Commetor Date
HEATING UNIT (TO 100.(100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER 100.000 BTU)
Will thcapplicant or future building occupantstore tr handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
Code, Section 25532do?
❑ Yes ❑ No
ISST AlsoCE DATE
Willtheapplicanmrfuturebuildingoccupant ussequipmenmrdeviceswhich emit
Encoders air contaminants as defined by the Bay Area Air Quality Management
Encoders
BOILER- COMP QHP OR 100,000 BTU)
BOILER -COMP (OVER 1.,000 BTU)
P A
PAM
NEW RESIDENTIAL MECtI. SQ. FT.
❑ Yes ❑ No
requirementsof the
1 have read the Coe. materials requirements under
t
OCT 12
34. 1 un erst
gaiety Codc. Sestinas 255(15, and 25534. I understand that
California Health Safe,,
if the building does not currently have a tenant, that it is my responsibility to notify the
C! I i 'I
occupant of the requirements which must be met prior to issuance of a Certificate of
Ur
b :��rL f
Occupancy.
ISSUED BY:
Owner or awhorizcd agent Date
TOTAL: