25605APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
QHUILVENU -
CITY OF CUPERTINO
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION APPLICATION/PERMIT PLUMBING - MECHANICAL
PERM] 'I'NO.
25605
BUILDING ADDRESS:
SANITARYNO.
APPLICATIIONSSUBMMALDATE
rV LAR12LI UNIT # LOT #
/ate[ IC
VCONTR\OLp
OWNER(NAME : —
es
PHONE
CONTRACTOR'S NAME: �6 LIC NO:
G—
N/C
❑
RCIIITECDENGLNEER:
ff
LIC NO:
ADDRESS:
ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
E] 11
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed underpmvisionsofChapler9(commencingwith
OSection 700(F.f Division3 of the Business and Professions Code,and any license is in
APPLIANCES -RESIDENTIAL
OB DESCRIPTION
PANELS
F full force and effort.
U License Class Lic.N
Date Contractor
UPT0200AMPS
201 - 1000 AMPS
to
'T. ARCHITECTS DECLARATION
OVER 1000 AMPS
SQ. FT. FLOOR AREA $/SQ, IT.
O 1 understand my plans shall be used as public records.
J
,TION
SIGNS ELECTRICAL
Licensed Professional
Q OWNER-BUILDERthe CyATION
V 1 hm that ereby affirm 1 am exempt fromm the Contumor's License Lew Farm
in following mason(Section 7031., Business and Professions Cade: Any city or county
which requires a permit m conssmct, alter, improve, demolish, m repair any stmnure
prior to its issuance. also requires the applicant,such permit to file a signed statement
p that he is licensed pursuant to the Provisions of the Contractors License Law (Chapter
(.VAL
a 9(commencing with Section 7000) of Division 3 ofthe Business and Professions Code)
SPECIAL CIRCUIT/MISC. "
TEMP. METER OR POLE ISM
POWER DEVICES
SWIMMING POOL ELECTRIC
m or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
4 Section 7031.5 by any applicant for a permit subjec,,the applicam m a civil ponalty of
n;,ynote than five hundred dollars(5500).
p ��I mownerofthepro ny,ormyemployccswithwagesmtheirsolecompensadon.
will do the lurk, and lM1e swuureisnatinunded.,offered far sale (Sec.70a1L Bmmt,ss
-
-
OUTLET'S - SWITCHESFLXNRES
NEWRESIDENTIALELECIR_SQ.FT.
STORIES
TYPECONSTRUCI'ION
and Professions Code: The Contractor's License Law does not apply to an owner of
,
propertywho builds., improves thereon,and whnd,.suchwork hinamt or Nrough hisown
for
cmr,the
ne ear.
OCC. GROUP
RES. UNITS
TOTAL:
oomplfered
bs,pingor itpowehimprovemwithin oomef,
however,thethe burden of mentishat sold he id not build of completion, thrower-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
1e')'
❑ propen,14. exciuBusiness
FLOOD ZONE
APN
fnuassions CWcemedconvamcrsto
Lnxwd the project (Sec. oano ncrofvs and Professions Codeq The Convectors
uct the project
does not apply manowneroa,cc,mny whobuildamatumdre Nue.n.end
PERMIT ISSUANCE
whoa.Law
who nommen fmsuch projects wiN acomruao,(s) licensed pursuanuo Ne Contmcmrs
License Lnw.
ALTER -DRAIN&VENT -WATER (LA)
FEE SUMMARY
❑ 1 am exempt under Sec. . B & P C for this reawn
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RF.CEI"it
Owner Unto
DRAINS -(LOON. ROOF. GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ I hereby affirm than have, roficum of common m sel r -insure, ora cmlfico¢ of
orken'Compevominn lnsuranceoracenified copy them.f (Sex. MOST Lab C.) which
cover, all employee's under this permit,
Policy #
FIXTURES - PER TRAP
RECEIPT#
PARK FEE Y N
RECFIPT g
GAS - EA. SYSTEM -I INC. 4 OITILE X
BUILDING DIVISION FEES
Company
❑ Coifed copy is hereby famished.
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEE
GREASE/INDUSTRI. WASTE INTERCEPTOR
GRADING FLEE
❑ Cenitiedcopy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER -SANITARY -S'T'ORM EA. 201
ENERGY FEE
(This section need not be completed ifthe permit is forone hundred dollars(SI00)
or less.)
WATER PLATER WNW/ELECTR
'
I cenify that in She performance of She work for which this permit is issued, l shall
not employ any person in any mounteras to became subject to the Workeri
so
PAID
WATER SYSTEM/IREAONG
Cnnlpentuinn Lawsof Califomia. Date
Date Receipt or
Applicant
1 NOTICE TO APPLICANT:If, after making this Certifies. of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FIE
TOTAL:
Compensation proomofirsofthe Labor revoked. must
I becomesubjectcompyr the such
forthwith comply with such provisions or ,.his pemut shall h darned revoked.
BUILDING Fleli
SEISMIC FEF
I CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FLEE
Lenders Name
QTY. MECHANICAL PERMIT FEE
PLUMBING ME \
MECHANICAL, FEF
Lenders Address
1 I century that 1 have read this application and sum that the above information is
correct. legree mc.mplY with ell city aM <ounry.Minanasand sale laws rels0ngto
PERMIT' ISSUANCE
j building construction, and hcrebyauthonm mpresenudvesofthiscity m emerupon the
above-mentioned property for inspection purlvses.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT Q"010,11(0 CFM)
(We) agree w save, indemnify and keep harmless the City of Cupertino a,mmor
.liabilities,judgments. costs and expenses which may in any way acemeagainssaid City
AIR HANDLING UNIT (OVER 10.000 CFM)
in umscyuenee of the arcing of this permit.
—
BXHAUST11001)(W)DUC19
PAID
SSgnartmof Applicur/Corniirsum Da¢
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt is
HEATING UNII'(OVER 10TOC) BTU)
TO
Will She th, Cupenim, mrehuildi Code,Camstorem anddlc Hiciddousmamety
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health trod Safety
VENTILATION FAN (SINGLE BE ID)
Code, Section 25532(a)1
❑ Yes ❑ No
ISSUANCE DATE
Wilhbeapplianmrlimurehulldingrc upanS a� equipme to rdevic vwhicM1 emit
BOILER - COMP IMP OR 100,000 BTU)
BOILER -COMP (OVER 100.000 BTU)
. cvdous air mm a .. as x ob finwl by the Bay Arca Air Quality Management
f� A
Pf /k
DHtrimp
NEW RESIDENTIAL NIECE. SQ. IT.
❑ yes ❑ No
the hazardous materials requirements under Chapter Si 95 of the
a do &Safely Code. Sections 35505,25533 and 25534. lundcrsunJthat[,F
OC ,p
l011�
Lread
does not currently have a tenant, that it is my responsibility to notify the
the myurementswmusbe metprimmisthnrimd
va7
ISSUED BY:
agent Date
T