25356 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DB,UI U-hLECTRI AL PFRM1I'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 25356
N r ^ f� /S
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION L t`'/1 3 5 1`�J
B UIh9CAI)al`IRESS: r SANITARY NO. APPUCATTIIOkN SUBMITTAL DATE
L l}A/(V UNIT# LOT#
OWNERSITAME
4o pH ���CONTRACTOR'SN LIC NO: Mp
All A r WillS N/C CONTROL
RCIII'FICf GINEER: UCNO: RES ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB "CIE
PERMIT ISSUANCE. �
El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL LOB FSCRI ION
WOO Thereby offirm of Division
amlicensed inss and flaifesofe,Coer9(commeneise with Q Pj
WOO Sealore(#10)ofDivisionaoftheBusineaeandProfessionsCode,andmylicenuisin ppNB15
�U� full force vnd effect.
La.,Zfu License Class Lic.It UP T02W AMPS
rnQ y Dale Convector 201-1000 AMPS
7_O,z ARC)IITEECTS DECLARATION OVER 10(U AMPS SQ.M.FLOOR AREA S/SQ.FT.
O Z^O 1 understand my plans shall he used as public records.
P�L W SIGNS ELECTRICAL
Q,1�,, Licensed professional
OWNIiR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm t
O a F hat 1 am exempt from the Contractors Liccuse Law for the
m�Oa following reason,(Semion7031.5,Business and Professions Cede:Any city or county TEMP.METER OR POLE INST. / f
which requires a permit m construct.alter,improve,demolish,or repair any structure `I
prior to its issuance,also requires lheapp)ivent for such permit to file a signed statement POWER DEVICES
5
MO that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 11 '� I
dXoX, 9(roOW
nanencing—th Section] )of Division3oflhe Businessand Pmfevions Code) SWIMMING POOL ELECTRIC t) I\./il UATION
Xyl, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS 1—ZQ Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of FIXTURES
X50 not some than five hundred dollurs(S5W). NEW RESIDENTIAL ELECITt S 1
�F. ❑ I,as Ownernfthepmpeny,rrmyemployeeswith wages ntheirsolewmpensati0n, Q _ J TYPECONSTRUCIION
a3— will dm he work,mal the stmaure is not imendeximOffered fm sale(See0066,Business
and Profession.Code:The CDmmcusrs License law does not apply to an owner of
property who buildsmimproves game ,lead whodoe such work himself.,aa nigh his
ownemployms.pmvidedthat,suahimpmvemonLsarenotintendedorofferedfmmle. OCC GROUP RES.UNITS
however,the buildings improvement is sold within one yearof completion,the owner-
builder will have the burden of that he did not build m ire T L:
Moving prove fm puryou oftk
ani
❑ Las the pr ject propeny,am Business
ss and onvactiions C ac:)The onetorsm QTY' PLUMBING PERMIT FEE FLOODZONEpPN
sense the project(Sec.o an o Business and Professions Code:)The Consmaand
License Lawdrcsnmapplytonn0wna0fpropeny whnsed puroimptothe Contractors
PERMIT ISSUANCE
Lice.trecu fosuch projects wiNaconttacmrts)licensed Oursuanuo Ne C.mtacmrs ALTER- ( )
Littnm law. DRAIN&VENT-WATER EA FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT,DEVICE O .IUF.FF,ES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,ARE FA,COND. RECEIPT'#
c WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y_N_
❑WorIthkers
Co affirm thalhave a urance enifcatfie copytheralcm eof(Snure,or Lm
C.)atche.f FIXTURES-PER TRAP RECEIPT#
Workers'Cnmpenmtinn lnsumnceora cenified copy there.f(Sec.3gW,LabCJ which PARKF'EE Y_N
cover,all employee's under this perm. GAS-PA.SYSTEM-1 INC. OUTLETS RECEIVE'p
Policy n BUILDING DIVISION FEES
Company GAS-HA.SYSTEM-OVER 4(EA) PLANCHECK FILE
❑ Ccnilied copy is hereby FumisheA.
❑ Certified copy is filed with the city inspection division. GRF.ASMNDUSTRL WASTE INTERCEPTOR GRADING Ri13
CERTIIICA'I H Or EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Ibis section need not be completed if Ne permit is for one hundred dollars($IW) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less)
I certify that loth,permmbeeofthe work for which this permit is issued,Isha)1 WATER HEATER WNFNT/ELECE
not employ any Person in any manner s.as 10 become subject to the Workers PAID
z Crmpensaionlawsof Celifomim. Dam WATER SYSTEMI'TREATING Date Receipt If
t
z O NOTICE TO APPLICANT,If.after making this Cenificme of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT, TOTAL:
FW) become subjectto the Workers Compensation Provisions of the labor Cade,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
zI z 1 hereby affirm Nat thea is a conanunion lending agency for the perfoornmee of
U O the work for which this permit is issued(Sec.3099,Civ.C.) TOTAL: ELECTRIC FEE
Leaders Name O U Lender s Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and sure that the above information is
F qAt
1 correct. l agree to comply with all city and county Industries and sum laws relating to PERMIT ISSUANCE, MECHANICAL FEE
_ �y building construction.and hereby authorize representatives ofthis city treater upon the
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree t0 save,i dem 'Fy and k rmless the City of Cupertino against
liubilities,judgme x.vu and prosmmt,rIrmywayxc.i,agpma.id City AIR HANDLING UNII'(TO I0,000 CFM)
in consequence he r f pe i.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si mmrcof Appliema/Contr are EXIIAUSI`HOOD(W/DUCT)
PAID
))AZA S MATERIALS DISCLOSURE I HEATING UNIT(TO IIX1,011)BTU) Date Receipt#
Will the applicant or future building occupant store or handle Hazardous material
as defined by the Cupertino Municipal Cole.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I W.0110 Bl'Of
Crile,Section 25532D)9
❑Yes C3 No VENTILAI]ON FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
Will tai,co icani Drlmare building by the Bay equipment Quality
es Marrwhich est /q��yp
hazardous air conmminanu n defined by the Bey Arca Air Quality Management BOILER 1 00,000 BTU) P 4
. DimricC #'Y ® D
❑Yea ❑No NEW RESIDENTIAL MECII. gQ.FT. uOI`!
1 have mazsm
ad the hrdous mermix rx mmments under Chapter 695 of the w0 26 ��
Celifomia Health&Safety Code.Section 25505.25533 and 25536.I undersand dor
if the buildinge a nt
donor currently have tena ,that it is my responsibility to notify the
occupant of the requircm<nu which must be met prior to issuance of a Certificate of Chi Vr
93
Occupancy. �rtr.L,llrVr
Owner or authorized agar Date
ISSUED BY:
OFFICE