25051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OF CUPERTINO L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25051
BUILDING ADDRESS:
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
L4 y SANITARY NO. APPLICATION SUBMITTAL DA'I
I UNIT# LOT# w
OWNERS NAME: _ PHONE: j4<'G ) TRACTOR'S NAME: / ,,I i /LIC NO:
IIJtom. ;`5`l�c+ u(l C G>vk 1 G� L _NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: AD S: ❑
P,),f c
Zf 3 7ti 6 f�u i' 7'� 2+v
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CONTACT: PHONE: BUIMING PERMIT INFO
QI Y. ItIC PmkmT FEE
BLD E ECT P MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESID
p Z 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with JOB DESCRIPTION
P.
FOO Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
cg�<W F full force and effect.
Q z W i License C s Lie.# TO
vl^i 4 Date Contractor 2 1 1
0 I'-'"z ARCHITECT'S DECLARATION 1 PS SQ.FT.FLOOR AREA $/SQ,FT.
�►Q 1 understand my plans shall be used as public records. 163 � w
F�►a; SI SE C'IRIC /7V�7
Q ,, Licensed Professional
a rL U. OWNER-BUILDER DECLARATION SPE AL CIRC C.
X O a.F I hereby affirm that I am exempt from the Contractor's License Law for the
W 3(L following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER R POLE IN
which requires a permit to construct,alter,improve,demolish,or repair any structure
W)•• prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W E4 O p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a-CL M 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ECTRIC VALUATION
W or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
k—Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of UTI ETS-S WIT HES-FfXTURES
CJ not more than five hundred dollars($500).
property, Y P Y g •compensation, NEW RESIDENTIAL ELECTR SQ.FT. ORI TYPE CONSTRUCTION
ro ❑ Las owner of theOrin employees ees with wages as their sole
a,3„I will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or throu
own employees.provided that such improvements are not intended or offered forsal OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the ow
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owner of the property,am exclusively contracting with licensed contractors to PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law does not apply to an ownerof property who builds or improves thereon,and PERM ISSUANCE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) M
FEE SUMARY
❑ I am exempt under Sec. ,B&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#SCHOOL TAX Y N
❑ I hereby affirm that I have a certificate of consent to self-insure,or a certificate of AASWRA
RECEIPT#
Workers'Compensation Insurance or a certified copy thereof(Sec.3900,Lab C.)which PARK FEE y N
covers all employee's under this permit. .4 OUTLETS RECEIPT#
Policy# �_ BUILDING DIVISION FEES
Com 4 EA)
� Certified copy is hereby furnished. R ( PLANCHECK FEE
❑ Certified copy is filed with the city inspection division.
STEINTERCEPTOR GRADING FEE �.w
CERTIFICATE OF EXEMPTION FROM WORKERS' SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100) SEWER-S RY- RM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER T CTR
not employ any person in any manner so as to become subject to the Workers' PAID
Z Compensation Laws of California. Date WAT TE ATIN Date Re #
Applicant
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW R� L PL SQ.FT. TOTAL:
�--� V] become subject to the Worker's Compensation provisions of the Labor Code,you must �—
? forthwith comply with such provisions or this permit shall be deemed revoked. M
Pe 7ELECTRIC
EE (XJ
rr
Q CONSTRUCTION LENDING AGENCY 1
I hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) ELender's Name
Lender's Address QTY, MECIIANI ER T FEE FEEI certify that I have read this application and state that the aboveinformation is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE L FEE
F' building construction,and hereby authorize representatives of this city to enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. !.r CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
j in a uence of the granting of this permit.
\ AIR HANDLINGE(W/DUCT)
T(OVER 10,000 CFM)
Si ature of Applicant/Contractor Date EXHAUST HOO
PAID
HAZARDOUS MATERIALS DISCL URE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 532(a)?Ye532(a)? El No VENTILATION FAN(SINGLE RESID) L
t
Will the applicant or future building occupant use equipment or devices which emit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? ,.
Yes 11 No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the ,{
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the budding does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. Z) I
Owner or authorized agent Date TOO „A 11'll
- -- --- ------- ----- - - --- ----- A ISSUED BY: