25588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB .
ILDI - ]LL;TRI,AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
B 25588
BUILDING DIVISION u1LU1NGPROJftCTIDEN'f IIrICATION
BUILDING ADDRESS: n SANITARY NO, APPLICATION SUBMITTAL DAI`E
VCON"encs ee UNIT# OTp
OWNFp{,�RS NO
��: PIIONI?:
A ' 'S AMr LIC NO:
FIX, CONTROL#
RCIII'ITCr/ENGINEER: LIC NO: A ❑
'ONTACT: - PHONE'
QTY. ELECTRIC PERMIT PGE BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE 1'� 11 0 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-REST IAL f0` TOB DISCRIPTION
nczz I herebyaffirmtha,Is.lice...udmier ownims.02mpterr)mimmencingwidt
woo Scetiun 70IXB of Uivision3ofthe Business enJ Professions Code wdmylicememin PANELS
{{Lt�1E❑q full fares and of
,<I ly 'ecu s " I,Ie.# ��� UP T0200 M
m= Dae-lel GonlRcfpr �. 201.10(10 S 5 IT.FTOOORR AREA $/SQ.FT.
ZO,7 ARC]I,M.CT'SDECLARATION OVE AMPS Q�
O Z—cl 1 understand my plans shall be,used as public records.
7:1
qyS� ,,] Licensed Professional N ECTRACAIN
y�
�$ N< OWNER-BUILDER Dthe ComTON S AI. IRC C. r
OaU I hereby af0nn ma I an exempt from the Contmnors License Low I'nr the /+
LL3LLy fallowing reaarm.(Sectfon 7031.5,Business and Professions Code:Anycilyorcnunty EMP. E RPOLONST. �� Ip1 Ip' ylI
°N�� which myulrcs o permh to amssuct,alter,In,provo,Jemoliah,or mpmr uny ebuctu¢ POWER 1 rV CES { I is s1,.Y
Y� poomoika iuuana,also reyuirea the applicant forsuchpcnniuofileasigncd atatemeon v000
p0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
damSWIMMING POOL ELECTRIC V L N
o 9(comcncingwitb Section70W1of Division3ofthe Businessmdpofessionsfide)
W_tn unbar he is raempnherefrom and the basis farthealleged exemption.Any violation of pUTLL'fS-SWITCHES-FIXTURESuAT
FZa, Section 7031.5 by my applicant for a permit suhjects the applicant to a civil penalty.(
not more than five hundred dollars(5500).
O NEW RESIDENTIAL ELECTR'_SQ,FT. STORIES 'TYPE CONSTRUCTION o ❑ Lasnwncrnl'thepmperty.ormyanployees withweges ustheirsolecompensvtion,
y3°�° will dorhework.ande amcmreisnslimm�eedc Law
apply ,, aBusiness
and Professions Calc:Thu Cnnsumoh Llcenao Lvw does not apply m an owner of
propertywhobuildsorimprovesuhereon,and who does such workhimselforOmiugh his
entployeeapmvided thttsueh improvemrntsare not intendeduroHered forsele.If,
OCC GROUP RFS.UNITS
however.the buildingor improvement is sold within one yearrifcutnpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
We.).
❑ I,asowneroftheproe",amexclusivelycontmciingwithlicensedcontmctmio QTY' P1,UM131NG PERMIT FEE ILOOD-LONE APN
....true[the project(Sea.7044,B.6ticas and Professions Coda:)The Cialm m'x PERNIFIASSUANCH
Lirenx Law Joes nm apply m an owner afpropmy who builds or improves(hereon.enJ
who contract,for such projects with acoutmetor(s)licensed pursuant to the Contractor's ACIBR-DRAIN&VENT-WA'IP%(I?A
License Law. ) FEE SUMMARY
❑ 1 vm exempt under Scc. ,B&P C for tots reason BACK FLOW PROTECT.DEVICE, OUTSID(•FE
SANITARY Y N
Owner Dau RECEIPT
M
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMI'1?NSA'1'[ON UT;CLANAT'ION SCHOOLTAX YN
❑ Thereby affirm thalhave ecmifcau nfconxnt to self-insure,nrerenificam of RECEIPT
Workers'Gcm t 1 ITXTURIS-PER'IRAP
( pens..innnmrancc nramrtiOeA copy thereof(Sec.3A00,lahCJwhich PARK FRF. YN
IPI 4—
Point cy pll employuh under this it f,�� GAS-P.A.SYSTEM-I INCAOUTLETS BUILDING DIVISION FEES
Company � l pwl�"JkGAS-EA.SYSTEM-OVER4(EA) PLANCIIECK FEF.
Cenificd copy is hereby famished.
❑ ._Ia fled copy is filed with the city inspection division. GRFASEONDUSTRL WASTE,INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section cordon,beconmord iftbe permitnformushmsuctid.11mi(IOW) SHWER-SANITARY-STORM PA.20BAFT. ENERGY FBI.
! j or leas.)
I cenify that in the Performance of the workfor which this Penni[is issued,l shall WATER HEATER W/VENT'/ELECIR
nor employ any person in any manner so as to become subject ,,the WmIcere PAID
z Compensation Lawsof Celifomia. Dau WATER SYSTEMrMEATING Date Receipt#
Applicant
NOTICE TO APPLICANT:ILafar making this CeOibcem ofEmmption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
.Cn. brconm subject to Worker's Compensation provisions of the Labor Coda,you must
aiforthwith comply with such provisisrms orchis permit shall ba deemrevoked.
ed BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm that them is a construction lending agency for the Performance of
the work for which this peonit is i...ed(Sec.3097,Civ.C.) TOTAL: FLECIRIC FEE
I, CO-�. Lender's Name PLUMPING FEE
r^ Lender.Address QTY, MECHANICALPERMIT FEE
V 1 cenify that 1 have read this application and state that the clause mfnmr.don i.
W anrrent.lagrcetowmply with all city and mm�ly nrdinunoca and.tote lows tela ng rte PERMIT ISSUANC17 MECHANICAL FEE
buildingumununion,and hereby malmrimmpremundivesafmis citymenter upon the
V z shave-mentioned property for inspection purposes. ALTER OR ADD TO MECII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep bamdess the City of Cupertino against
liabiliti gmrnts,casb Acepenxswhich may in any way accrue against said Ciy AIR HANDLING UNIT(TO 10,000 CFM)
in c que eoftlic, - 6nIthis cmrlil.
AIR HANDLING UNIT(OVER IO.gNI CFM)
S p are EXHAUST How(W/DUC'P) PAID
HA'LARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO pOgWO B'TO, Date Receipt
Will the applicant or future building occupant store or handle hazardous material I IPATING UNIT(OVER 1 W,0(I(1 BTU) TOl'AL:
as defined by the Cuperim,Municipal Code,Chapmr 9.12,and the Health and Sammy
Cade,Section 25532(a)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
Will
BOILER-COMPLIHPOR 100,000BTU) ISSUANCE DATE
the applicant nr futurehuilJing oceupam useequlpmemnrdevices which emit
harmless air mmmonams as defined by the Bay Area Air Quality Management BORER-C IMP(OVER 100,B00 BTU) pp p(��
DDistrict? r ✓
❑Yes ❑No NEW RGSIUENTIAI.MECH. SQ.FT. ® A
DND1 have hand the huzalous materials reyuiiemems under Chapter 6.95 of the SEP 28 19
California I eidth&Safety Code,Sections 25505,25533 and 25534. l undersmncithat
if the building dws not curten0y hevcntenun,.mut it is my renpmsibilitymnatify the
cu,som.(,he e mel e tequimments which meal bpoor to issuance of a Cer ifieme of
uct cy. CI '.r T IOle
Owner or amhoozcd agora Dam 'f01'AL: ISSUED BY:
OFFICE