25809 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOLDJNG-FTFf'TRD'AI PERM 7 NQ r� p O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION GO
BUILDING ADDRETS.ti�s�/ SANITARY NO. APPLICATION SUBMITTAL.DATE
l� W WITMi TX LOT# I ��
OW .NAME: PHONE: CONTRACfOR'SN LICNO: NIC 1• CONTROLX
•ARCHITECT/FNGINEER: LICNO: DRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE 9 BUILDING PERMIT INFO
`Y'— ELECT PLUMB
PERMIT ISSUANCE
1-1 El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL BDFSCR�vWN
OzzPOO Thereby affirm Narl Tom he Business rund Prifesaf(.Tepte79ndmy scene with
+�S�O SMfon7000lofDivrslon7of the Business and Profeasiov Code,and my license lam PANELS
<Z, Lice rceand cffecl. IAA�
FZW License Clans I.ic.p UP TO 280 AMPS
mQDate Contractor r I�4JAy
s�L L•�j�(�
Z8vs4 ARCHITECTS DECLARATION OVER 1000 AMPS Q. .FLOOR AREA $/SQ.FT.
OZ-0 I understand my pluns shall be mud as public records.
m tel SIGNS ELECTRICAL
Licensedprofesxinnal n n IFK
c, OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MIS r (,.„/ �• g l�
X ii, 1- 1 hereby affirm Thal l um exempt from the Conuuctwes License Law for the
Maus. following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE IN
�Ol which requires n permit m comuum,ober,improve,demolish,or repair any swan..
C o,, priartoiuissumn¢,olso requims theapplicam for such Permitto file asignedamme
tent POWER DEVICES
ly�'MO thin he is licensed pursuant to due provisions of the Contractor's License Law(Chapter
W
'' ,E' 9(commencing wi ih Sectinn 7000)of Division 3 of the Business and Professions Cods) SWIMMING POOL ELECTRIC VAjTjk1,UON
_y or Nat he is exempt NcrtLom and the bmixfur the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
no,m red door
unndridoollan $500).tsubjecu the upplicont macivil penalty of
G not morethm rofthe mrc nylormyeml. NEW RESIDENTIAL El.ECTR —SQ.FT.
❑ olhewrk,andepmpeny,nrmyempinyeeswhhwogesasic(Sese compensinessSTORIES TYPE:CONSTRUCTION
p, will dathewons C d e:11m Conure ant
mimenerese Law
doist fs nor apply 71144,Business
and Professions Cede:7Te Cnmmmure License Lew does nor apply but an owner of
property whobaddsorimproves Ncrom,and wbodoes such workhimulfordsroughhis OCC.GROUP RES.UNITS
own employees,provided[list such improvements tic nut intended or offered intrude.If,
however,The building mimprovemem is sold within oneyear ofcompletion,theowner- TOTAL:
builder will have the burden of proving Nn he did nor build or improve for purpou of
sale.).
❑ I,in owneroffle property,smexclusively connecting with licensedernumbersm QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the pmjecr(Sec.7044,Business and professions Code:)The Cannazmr's
License Low does not apply man ownerofpropeny whobuildsorimprovesthereon,and PERMIT ISSUANCE
whoconuacu forsuch projects with a conn ume)licensed pursuant mNe Convectors
Licenu Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I nm exempt under Sec. ,B B P C for this reason BACK FLOW PROTECT.DEVICE SANITARY DUTY DE MUSN
Owner Dam RECEIPTX
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Ihertbyiffw'hat lhaveamnif ueefconunrtoul6insurt,maanificauef RECEIPT
Workers'Compensation Insurance or a mooned copy docomf(Sce.380),Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
coven all employees under This permit. GAS-F.A.SYSTEM-1 INCA OUTLETS BUILDING
p
Policy X BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is fled with The city inspection division. GREASEITNDUSTRI.WASTE INTERCEPT OR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need but lRecmplewl if Ne permit is ferrous hundred dollars($100) SEWER-SANITARY-S'T'ORM EA,2WF1'. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELIiM
not employ any person in any manner so as at become subject to The Workers' PAID
Compensation Laws of California. Dam WATER SYSTEM/TREATING Date Receipt IT
0 z Applicant
z NOTICHTO APPUCANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ITT. TOTAL:
(A become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provixioos or this pewit shall be deemed revoked. BUILDING FEE
W z . CONSTRUCTION LENDING AGENCY SEISMIC FEE g
^a 1 hereby affirm Nat them is a construction lending agency for the performance of "TOTAL: ELECTRIC FEE
U O the work for which this Pewit is issued(Sec.3097,Co.C.)
Lender's Name
OU Lender's Address QTY. MECHANICALITERMIT FI7E PLUMBING FEE
�
1 unify that 1 have read this application and state Nat Ntion e above informais MECHANICAL FGE" OW.. cmneer.I agree to comply with all city aM county ordirouc s and sure laws relating to PERMIT ISSUANCE
E-' 0,, building construction,end hereby audience reprorenurivesof Nis city To enter upon The CONSTRUCTIONTAX
U z above-mentioned property for inspection purposes. ALTERORADDTOMECIi.
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,ju snrs,cosa wdexpensn whichmay' enywryacaoeagainstseid Ciry AIRTIANDLINGUNTICT010,000CFM)
onconsequ c oft grunting of r s R
Wl AIR HANDLING UNIT(OVER 10.000 CFM)
S' naw of ApplicanUConrucwr EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE• - HEATING UNIT(TO IW,fq(I BTU) Doc Raccipt X
Will the applicant or future building occupant store or handle huallous roomer HEATING UNIT(OVER IIXI,INp RTU)a9 defined by the Cupe nine Municipal Code,Chapter 9.12,and she Health and Safety onge
Cede,Section 23512(u)'!
CIYe ❑No VENTILATION FAN(SINGLE RF.SID) Lo
❑
Will[heapplicunmrfuwrebuildingoccupam usceyvipmcntardevius whichemit
BOILER-COMP(3HP OR 100,00)0 BTU) ISSUANCE DATE
hazardous air contaminants as,defined by the Bay Area Air Quality Manag:M001 BOILER-COMP(OVER IOO,OIXI BTU) ^ O N p
District? /�
EI Yes [I No NEW RESIDENTIAL MECII. SQ.1T,
I have read the huzunlnus materials requirtmente under Chapter inno id the Nov a ����
Cd m buia irg does
Safety Gxle,have
it mount,
25505,25533 and responsibility
l underswod[list �9
ifcobuildingdoesornot cmrcnrlyhovenrennm,cl itismy rsupcei,)fa to notify the
occupow ol'thc m ulremcntx which must he met prinr'o isxuonoe of n Cenlficnm of C11Y
fXj
cmrymcy. _ j I j
o
Owner or uwharized xgeo Dam ISSUED BY:
OFFICE