25596 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO LD MECH'"RF A. PF:RMI'I'NO.
APPLICATION/PERMIT TING PROG-h1eDENTICAL
FIC
BUILDING DIVISION BUILDING I•ROJECT IDENTIFICATION
BUILDING ADDRESS: y SANITARY NO. APPI.ICA'1'IOONN SUBMH9'AL DA'IP
/ UNIT# LOT# 1��/-FaJ�1
OWNERSN O E: OTTMACTOR'S NAME/ C NIC Uq w CONTB�OLN��
RCDITT:Cf INF. 1 N AODR J �ry�/ ❑
ieffyNTA PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
321 PERMIT ISSUANCE A )G ELECT PLUMB MIiC11
1:1 El 1:1
LICENSED CONTRACTORS DFqLARLtiTION APPLIANCES-RESIDENTIAL
mwz Iherebyieffirm Nat l am licedud underpmvision5ofaapier9(commencing with /J. 1 lPCSCRI N
u100 Scedon 7000)of Division 3af the Business.nd Professim.;Code.and my license is in PANELS 7/J
FyU full force and effect.
FZ, License Class Lia# UPT02WAMPS �"�rq
mow
rn a y
Data Common 201-1000 AMPS 'K
ZOyZARCHITE'CT'S DECLARATION OVER 1000 AMPS SQ,Ff.FLOOR AREA $/SQ.IT.
CZ O I understand my plans shall be used us public records.
Ful� SIGNS ELECTRICAL Licensed Professional
�Ctt4 OWNER-BUILDER DECLARATION SPECIAL CTRCUIT/MISC,
x4x0 oL 1 hereby affirm that 1 em exempt from the Convenors License Law for the
y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�EZ ONC which ruluires a permit in construct,altar,improve,demolish,or repair any structure
E y',s.:R prior to its issuance,also requlms the applicant for such Permit o Bee a signed statement POWER DEVICES
p @m he is IicenseA pursuant m the provisions ofthe Commcmra License Law(Chapter
o.a 9(commencin with Section 7000)of Division Sof the Businessnnd Professions Code) SWIMMING POOL ELECT RIC
KO� (commencing `VALUATION
ty.,y orthat heisexempt If,anyrefromaddthe bmisfor the
ctsalleged,fivioi n.I...MIT
of owi.Ers-SWITCHES-FIXTURES b
Suvion 7031.5 by any eppllcemfor apetnit subjects the upplicammacivll penalty of O
fit] not more thio five hundred dollars($500). NEW RESIDENTIALELECrR _SQ.FT.
Zi_,,, ❑ 1. sowneroftheprop sty,ormyemployaswithwagesastheirselecomNnsmion, STORIES TYPE CONSTRUCTION
will do lbe work,maLhe structure is not imendedor offered for sale(see 70,0.Business
add Prolax naris Code:The Commnors License Law d.not apply mon owner of
propeny who builds or i mproves thereon,and who does such work himselfor through his
wnemploy...... that each impmvemenuxrenot intended oroffcrcd for Bole.If. OCC GROUP RES.UNITS
however,the building or improvement is sold within one ycmofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did rot build m improve for purpose m'
).
❑ I,asawner ofthe property,amexclusivelycnmmeting with licareadconbto
ucrs to QTY. PLUMBING PERMIT EEE FLOGU ZONIi APN
enustme,the project(Sec.70,14,Business and Professions Code:)The Contractor's pERMITI SU
License lawsuits misapply to an ownerufpropenywho builds orimproves thereon,and , nri, qt
whocommenfimsuch Temicats withse.mrsetor(s)Iicensedpursuamtothe Commemre AIAER- RAI &VEN'P-WATIiR F.Aj' t
License Law. _ PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW P OTE&.DEVLCIT II LO DE FEE,
J II 'ANI ARY YN
Owner Date wRECEIPIT
WORKMAN COMPRNSATION DECLARATION DRAINS BOOR.ROOP�AREA,COE 'I CH LTA% Y N
❑ E hereby at rim that l have a certificate ofennsent to self-Insure,or a cerolale of9V' lixi
RECP.IITN
Wmk. oro FIXTURE -1'ER 1'
cove�rslit f� penubon lnsumnce oreccnified copy thereof 15tt.3g00.lcab CJ which ��PAR PEE YN
°i�s tq GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
policy N � BUILDING DIVISION FEES
Company 2 _ RZOW n GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Centfic copy is mrchy fumished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FIJI
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This union need not be completed lithe permit is forone hundred dollars($IN)) SEWER-SANITARY-STORM EA.200IT. ENERGY FEE
or less,)
I cenifythttinthe performance nflha week farwhich Nis permit is issued,Isbell WATER HEATER W/VENT/E6ECTR
not employ any person in any m as to became subject to the Workers' PAID
Compenutionlawsof C.Ofomia. Date so WATERSYSTENOTREATING Data Receipt#
Q Z Applicant
z C NOTICE TO APPLICANT'LIf,.ftm makin,dos Cenilicmemf Exemptiogyou should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
p) became subjectto the Worker's Compensation provisions ofthe Labor Code.you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE .0'aA,
CONSTRUCTION LENDING AGENCY SEISMIC FEE?
z lherehyaffirm taildoue is.r.rvaunian lendingugency fmthepmOunr anee of 'TOTAL: II.EC'TRIC THE
The work for which this pemdt is issued(Sm.3077,Civ.CJ
Larder's Name v
OF Lender's Address QTY. ". MECHANICALPERMIT FEPLUMBING FEEE.
U I cenify that I have read this application and state that the above information is
Lk1 correct. l agree it)comply with all city and county ordinances andstate laws relating to PERMIT ISSUANCE MECHANICAL FEE
Fy building construction,and hereby suthome,representatives of this city to enter upon The CONS'T'RUCTION TA%
U 7 ahnve-mentioned property for inspection purposes. ALTER OR ADD TO MECI I.
o-�- (We)ngova m save,indemnify and keep harmless the City of Cupertino against
liabilitice.judgments,costs and expenses which may many waymemeogamsts dCity AIR HANDLING UNIT(TO I RON CFM)
in; quenceof egreminB of permit.
A��^ AIR HANDLING UNIT(OVER IO,000 CFM)
elalb
Sl rmuro of ApplicanUCnot ter Doe EXHAUST HOOD(W/DUCT)
PAID
IIA' GUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HGTING UNIT(OVER IIX.000 BTU) 'TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(e)7
11 Yea ❑No VENTILATION FAN(SINGLE RESID)
id
Will tat,cmiceardaus s defined!by The ruse equipment Quality
Management
BOILER-COMP TRIP OR 100.007 BTU) ISSUANCE DATE
hara et? air wntatninanB as Aefinrd by the Bey Arca Air Quality Men.gemam BOILER-COMP(OVER 100,0011 BTU) PAID Ilisuia9 Yom' w ,D
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.P1'. �'g
I have read the hazmdaus muteri.la rcquiremems under Cloutier 6.95 of the Oct
California Health&Safety Code,Sections 255115.25533 and 25534. L understand Thal ti'i
if The building does not currently have a tamed.That it is my responsibility to notify the
OceLprot of the mquirenmma which must be met prior m issuance of a Certificate of ..
ccupancy. ��� V
Owner oramh.nited.,cut Dam TOTAL: ISSUED
OFFICE