25293 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIJI'"7NG-ELECTRICAL I-EMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
1 /� f1(� f�
BUILDING DIVISION
BUILDING PROJECT'IDENTIFICATION L LJJ
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
aw 'lfNIT Is' I.OTM
OWNIAWyirsfmy PRONE: CONTRACTOR'S NAMF LICNO: N/C CONTROL
h 7
ARCH E /ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY RLECTRICPERMIT FEE BUILDING PhRMI'1'INFO
BLDG ELECT P UMBMECH
PERMIT ISSUANCE -9 'El11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 0LOB DESCRI
tF
paIhembynffimt that l andicensedunder pmvisionsofChapter9(commencing with
0z Section 7")of Division 3 ofthe Business and Professions Code.end my license is in PANELS
full farce and effect. n
aZW Liccnx Class Lick UPT02MAMPS
rFilQy Date Contrectm 201-1000 AMPS
ZQN7,� ARCHITECTS DECLARATION OVER I"AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0 Z E use
1 understand my plans shall he d as public records.
F- SIGNS ELECTRICAL
s y:, Licensed Professional
C CLQ OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
k 3O u L nsherebymason.
n.St that I am exempt from the Professions
Co License law for the ' ■
ul rJdn followingreason(Section 7031.5, t..]an,land ve.demolish.
Co de:Any city orcounty TEMP.METER OR POLE MST. N
which requires a permit m mMSffie ultra,improve,demolish,fi repair any suvture
feea� pas he ilissuancgalmreyuires Nevisiinof the CopemuuoLiease La Etmemem POWER DEVICES
Ky �p
has he islicensedpuoction theprovisionsof the Contractors aidProessi(Chapter
9t hat he is exemwith isechnt 00mand at basis Divi
sion rdo Ie Business and Profession.ion Cod e) SWIMMING POOL ELECTRIC sssra��T w� U TI N
W ern or that he iseaempr Nertfrom and Ne basisfonhe mleged exemption.Any violation of OUTLETS 2l{
1-.�¢ Section 7031.5 by any applicant for a permit mhjects the applicant to a civil penalty of v
^W G not DAM
ore than five hundred dollars($SW). NEW RESIDENTIAL ELECf0. _SQ STORIES ECO STRUCHON
K � asownerof1h.p.,U.y,.rmyemployces with wagesatheirsolecia peresumm,
a3,. wil do work,and the stmctumis not intended oroffered foraale(See.7044,Boinesa
n Professions Code:The Contractor's License Law does not apply men owner of
propenywho huildsoflmproves Nermn,and whodoes suchwork himuelforthroughhis
own employccs,pmvideddat such imtavemcmsare not intended aroffered I..ale.If. OCC.GROUP RES.UNITS
however,the building arimprovernam is sold withinoneyeaofcompleums,theawnn- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑. Las ownera0he property,sat eaclusivelycontracting with licansedcontactoato QTY. PLUMBING PERMIT FRR FLOODZONI! APN
construct the project(Sec.71144,Business and Professions Code)'Me Connacmr's
License Lawdomsum apply manownerofpm,a,ny whobuildsorimpmvesthermn,and PERMI'I'ISSUANCE
whomntractsforsuchprojmtswiNaconnacmr(s)licensedpumumttmhe Conuactoes ALTER PA FT:R SUMMARY
License Law. GIA)
❑ 1 am exempt under Sec. ,B&P C for this rcaon BACK FLOW PROTECT.DEVICEE
SANITARY Y—N
—
Owner DatoRECEIPT#
TI
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSAON DECLARATION SCHOOLTA% YN
❑ Ihemhy effvm thetlheveaceniMam of conssmto self-insurt,a.seenifcateof FIXTURES-PER TRAP RECEIPT#
Workerv'Compensation Insurance ora certified copy thereof(See.Jg(q,lab CJ which PARK FFA] Y N
coven all employee's under this permit. GAS-EA.SYSTEM.I INC. OUTLET'S RECI?IPT p
Policy# BUILDING DIVISION FEES
Company GAS-IA.SYSTEM-OVER 4(IIA) PLANCI IECK ITE
❑ Cmified copy is hereby fumishol.
❑ Certified copy is fled with the city inspection division. GREASP/MDUSTRLWASTEINTERCEPTOR GRADING FEF:
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Phis section need not has completed if Ne Permit is foroae hundred dollars($100) SEWER-SANITARY-STORM FA.200HT. ENERGY HE
or lea.)
I unify that in the perforntsmce of the work for which this permit is issued,l shall WATER HEATER W/VENVELF.CIR
not employ any person in my manner so in to became subject to the Wnrkcrs' PAID
Compenation Lawsof Califomia. Date WATER SYSTEMnREATING Date Receipt is
2 Applicant
z 0 NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
H4 become subject to the Worker's Campemadm provisions of she labor Code,you must -
a7 fon ,viN comply with such provisions or this permit shell be deemedl rovoked. BUILDING ME
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.Mnm thus there is a construction lending agency far the performance of
V O he work for whicb Nis permit is issued(Sec.31197,Civ.C.) L:
ELECTRIC FEE
Lenders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEL? PLUMBING FEE LAI ^
I certify that I have reed Nis it hemion and state that the shove information is
correct. I agree to comply with all city and county ordinances and note laws missing to PERMIT ISSUANCE MECHANICAL FEE
Uj buildingco..traction,and herehymthmize representmivemfthiscity roamer upon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree 1a seat,indemnify and keep harmlea she City of Cupmino against
liabilities,j mems,nµ.andexpenseswhichm y inmyway.cvom.gpm sIamd ity AIR HANDLING UNIT(TO I0,"CFM)
nccnxyu c of@ Sting of Rlx
3 AIR HANDLING UNIT(OVER 10,MCFM)
StaF o p cant/Contractor Dae EXHAUST ROOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE I IEA'TMG UNIT(TO IM,"BTU) Date Receipt 11
Will the applicant or future building occupant store or handle hanNous mamral
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER I0f1,00t)BTU) TOTAL:
Code.Section 25532(a)?
❑Y CI No VENTILATION PAN(SINGLE RGSID)
Willth r connntrrfturc defined by than mss Area it unlit cawhich emit
BOILER-COMP f3HP OR I W,fNg)BIT) _ISSUANCE DATE
hazardous air cmnminants a Defined by the Bay Arca Air Quality Managcmcm BOILER-COMP(OVER 100,M)BTU)
District?
Dyes 0N NEW RPSIOENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cole.Sections 25505,M533 and 25536.1 understand Nat �6 }
iflhe building does not currently haves masa,that it is my responsibility to notify Ne /
occupant of the requirements which must he met prior to issuance of a Cenifimte of
Occupancy. , Uh G'✓✓ht
Owner or authorized agent Date TOTAL: ISSUED BY:
0