25815 (6)I PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING-RLELTRTCAT. I PERMIT NO. 2 5 8 1 5
CITY OF CUPERTINO PLUMBING. MECHANICAL.
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PRIIJRCT IBRN'I'IF'ICA'I']ON
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O S HONE: CONTRACT 'S NAME: ^ S
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BUILDING PER INFO
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LICENSED CONTRAM OR'S ECLARATION APPLIANCES- RESIDENTIAL
Ihcmbyaff,. bar l am licensedunder movisioruol'ChuMer9(commencing with
Section ]0N))of Division 3ofthe Business and Pmf..tons Code, and my license is in PANELS
JOB DESCRIPTION
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I.icenu Class Cie. # UP T0200AMPS
201 1000 AMPS
Dole Contmewr -
ARCHITECTS DECLARATION OVER 1000 AMPS
1 understand my plans shall be used n public recoMs.p
SIGNS ELECTRICAL I
SQ. FT. FLOOR AREA
/'s L E 8000N
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$'SQ. IT.
licensed Professinnnl OWNER -BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby eff,. that 1 am exempt from the Contactors License Law far the
following mason (Section ]031.5. Business and Professions Code: Any city me...ly TEMP. METER OR POLE INST.
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which requires a permit to construct, alter, improve, demolish, or repair any snveture
prior to its issuance, also requires the applicant for such permit o rile a signed statementPOWER DEVICES
,hat he is licensed pursuant the provisions of the Contactors License Law (Chapter
9(comnincing with Section 70W) of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC
or that he its exempt lherefmm and the basisfor the alleged exemption. Any violation of OUTLETS - SWITCHES - FIXTURES se
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nm mom than Eve hundred dollars (1500). NEW RESIDE fAL Fl EC —SQ FT
❑ lahow theproperty.ormyemployeorofwageaahalei(Sec.
VALUATIO
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STORIES
TYPECONSTRUCTION
mp
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rk,af
Business
voldo for 0,14.8 amass
intendederos,
sions
will dolliProfessions
he Co.isnnt
Coad,,and
does not apply lf w owner of
aro pmfnhiobu Code: The Comrenors License Low of apply or an
property oes
mpl.y.uildsorimpmves Nctmn. and whodmssuch workhimulforthroughhia
cmr,thebs,p buildingorimprovdvDhal eh improvememsme not intenaedorplethi Jfor owiml
huilder, willof pmentishathwithinoneyearofcomolve for theowner- T
builder will have the burden of proving That he did Trot build or improve for purpose of
eavethe burden
OCC. GROUP
KES. UNITS
talc.). QTY, PLUMBING PERMIT FEE
property, am exclusively contracting with licensed conlrmra,o
❑ I. as ownerof the propac
FLOOD ZONE
APN
constrain the project (Sec. )(H4. Business and Professions Code:) The Cantacmr's
License Lawdeesnot apply manownerofpmpenywhobreidaro PERMIT ISSUANCE
FEE SUMMARY
whacmmeh fn ... ch projects with,contractors, licensed pursuant
ato the Contmetors ALTER- DRAIN & VENT - WATER (EA)
License Law.
[jI em exempt under Sec. . B & P C for this reason BACK FLOW PROTECT. DEVICE
T§!i5H I BIS
SANITARY Y N
RECEIPfp
Owner Date DRAINS- FLOOR, ROOF, AREA, GOND.
WORKMAN COMPENSATION DECLARATION
EIIherebyaffiren that l have aceu nificrom ofcomenxzJl.immmmacemficateof FIXTURES - PER TRAY
Workers' Compensation Insurance or acvtiried copy thereoflSm. 380, Lab C.) which
Workers'
SCHOOL TAX YN_
RECIJI'I'p
PARK FEF: Y —N—
p
covers all employee's under this permit GAS - EA. SYSTEM -1 INC.4 OLD7LF7JS
BUILDING DIVISION FI!IiS
Policy N
Company GAS - FA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE115
E) Certified copy is hereby furnished.
❑ Ceniried copy is filed with the city inspection division. GREASE(INDUSTRLWASTEINTERCEPI'OR
GRADING FEE
SOILS FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE
ENERGY FEE
COrix section need not he completed if Ne Permit is forone hundred dollars DHOE SEWER - SANITARY - STORM EA. 200FE
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or less.)
WATER HEATER W/VENT/ELECfR
I cenify thin in the performance tithe wark for which Ntbject 1. the
not employ any person 1i any towner so as m become subject m the Workers'
Compenaetion laws of Califamia. Dam WATER SYSTIiM/I'REATING
Applicant NEW RESIDENTIAL PLMB. SQ. FT.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
PAID
Date Reccip(N
TOTAL:
BUILDING HE
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becumesubjecuo the Workers Compensation provision of the labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem is a construction lending agency for the perf.ce of OTA
the work for which this permit is issued (Sec. 30l Civ. C.)
Lendee,, NamcPLUMBING
SEISMIC FEE
ELECTRIC FEE Z
Q JE -30
FEE
0 F
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F-',0buitoingco
U 'Z
Z
Lender a Address Q'FY. MECHANICAL PERMIT FEE
--aU
MECHANICAL FEE
I cenify that I have read this application and state Nat the above information is
correct. I agree to comply with all city and county ordinance and sum laws relining to PERMITISSUANCE
stuninn, and hereby authorize reprosenmtives of this city to toter .upon....;;
above- c' nal pmpeny for inspection pmpusea. ALTER OR ADD TO MECH.
( e/ gma to save, indemnify and keep harmless the City of Cupertino again.
Iiabilin .j ms.cosrtund expenaes which may in any way sevum -1 tenacity AIR HANDLING UNIT (TO I It" CFM)
in cons a I'dNe'anli syn
J r On AIR HANDLING UNIT (OVER 10.0(0 CPM)
CONSTRUCT ION TAX
PAID
gamut of Applican4Canuavier Date EXHAUST HOOD OSMUC)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,001) BTU)
Date R 'p
Will...s, applicam or more Inildingoceuparn stem or handle hazardous ma¢nal HEATING UNIT (OVER 100.000 BTU)
as defined by the Cupertino Municipal Cede. Cham, 9.12, and the though and Safety
TO
Code. Section 25532(a)? VENTILATION FAN (SINGLE. RESID)
❑ Yes ❑ No
ISSUANCE DATE
Will the applicant or future buddingoccapam useequipmemordeviceswhich emit BOILER- COMP(3HP OR 100,000 RTU)
him dour air contaminants as defined by .he Bay Area Air Quality Management BOILER - COMP (OVER IM." BTU)
District?
❑ Yus ❑ No NEW RESIDENTIAL MECE. SQ. FT.
A
1 have mud ,he hazardous note ala requirements under Chapter 6.95 of ,he
®EC 171993
California Health & Safety Code, Sections 25505.25533 and 25534. 1 undermanJ Nat
if the building doe., not currently have a tenant (hat it is nay mxpsmaibili.y to entity the
cupw, of the res mar m nits which mus, be met pnar to issuance of a Cenificam ofEEE
Occupancy.
er-�
C UL V t Jr Cfi I ITV I
ISSUED BY: vk/-
Owner or authorized agent Date 'l yl