25559 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.- .-. PERMIT NO.
25559
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL BUILDING PROJECT IDENTIFICATION
BUILDING
ADDRESS: SANITARY NO. APPLICATIONSUBMTFI'ALDATE
UNIT# LOT#
OWNERS NAME' - I 1 ONE: CONTRACTOR'S NAME: LIC NO: 6�
NIC CONTROL#
A;111'IE�INECR: LIC NO: ADDRESS: ❑
( CONTACT: t PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
,.. VW w PERMIT ISSUANCE BLDG ELECT PLUMB Mto IEECtHH
LICENSED CONTRACTOR'S DECLARATION pppL1ANCES-RFSIDENTIAL UU ® L�
I hereby affirm that l an licensed under fChet 9(commencin with JOB DESCRIPTION
P400
yo ual Poionso per g
{ d E❑ Section]006 e f Division 3 of the Business erM Rofessioa Cade,and my license is in ppp)O-S � �C
pFj,UU fuccomeandeffect. r� /� •ms`s
L' u] License Class -� LiC.N �`1�-•'---s IIP T02011AMP5
L' at. Date Convector 201-1000 AMPS
v i� ARCHITECTS DECLARATION SQ.FT.FLOOR AREA stsQ. .
Z' rn I understand my plans shall be used as public records. OVER 1000 AMPS
F ria I"'t�i SIGNS ELECTRICAL
Licensed professional
aa' V OWNER-BUILD ER DE me Comment
SPECIAL CIRCUIT/MISC.
�(OyI_ IngreM1y n,(Se that 1 am exempt from Ne Conveaore e:Any
Law for the
41300 r¢n following remora(Section 7031.5,Business and Improve,
Professions Code:Any city or county TEMP.MEIF.R OR POLE INST.
k tam? which rcquiresa Pcmxtmconstruct,
,the.pltegimprovgh permiti,fit
repairmysouctne
`�Y� prior,.s lisensedfmsoant to the
Nevisios fin,the Co perminoLiease Law wemmt POWER DEVICES
yF°'j
that heis licensedp Sectio7theprovisionsof the Contractors License Law(Chapter
p-dXo�' Y(commencing with Section 7")of Division 3ofNe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m orthat he is exempt haefrom and the basis for the alleged exemption.Any violation of m ore OUTLETS
-$WITCHES-FlXTURES }� / J (/ O a V D
Q Secrirn703L5hy no;applicant for 4 permit subjects the applicant to a civil penalty of Z] ,
0 nmthan foo hundred dollars($500): NEW RESIDENTIAL ELECIR _SQ.FT.
❑ omownero the stpeny,ormycmplaya¢withwegnustheinole comp emanon, r $TORIPS TRU ON
p.
will dothewos,nod the structuralsnot inmicemseawdosnotpplyusloclorroffiened for side Business
of /A �(((�
and 1'mfusious Cade:The Convenors Liuuse law does not apply to an owner of
property whobuildsor improves Hereon,and whodoesiich work Nmselforthroughhisits
NIT
own employms,provided that suchimprovememe mermimended reoffered forage.If, 11 L
however,thebuilding orimpmvemem ismld withinoneyemofcompinion,theownm- TOTAL: race
builder will have the burden ofproving that he did not build m improve for purpose of - �V CYC
dale). ,;.1- DME
❑ I,uownerofthepmpeny,am ndusively cantrmtwgwithlammedconcommoro QTY. PLUMBING PERMIT EE APN
constmct the project(Sec.7044,Business and Profeseians Code:)The Contractor's
License law doesnotapply Coen owner Ofpmperty whobuilds orimpmves thereon,and PERMIT ISSUANCE _00
who conractsfarsuch pmjectswith ecentructor(s)limnsbInitiated athe Contractors se taw.
License
ALTLR-DRAIN&VFNT�WATER(FA) PEE SUMMARY
❑- 1 am exempt under Sec. ,B&P C for this recon BACK FLOW PROTECT.DEVICE T IDB ..S
SANITARY Y N
Owner Dote DRAINS-FLOOR,ROOFAREA,,COPD. RECEIPT#
WORKMAN COMPENSATION DECLARATION , SCHOOL TAX Y N
IMrtby offirm thatlhave ecmiftcete armnsmio.1f.insum,or a certificate of dao RECEIPT#
'Compensation Wuranee nr acerdfed co y thereof(Sec.3g00,LebCJwhich FIXTURES-PER TRAP PARK FEE Y N
•�SI emplaytt's ander,thia permit.
RECEIPT#
\ � GAS-EA.SYSTEM-I INC.40UTLETS
Policy# BUILDING DIVISION FEES
inat I' I GAS-PA.SVSTEM-OVER4(EA) PLANCHECK FEE
Certified copy is hereby ed q :t,
Certified copy is filed withsh five the city inspection division. GREASEBNDUSTRL WASTE INTF.RCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
- `COMPENSATION INSURANCE
(This section need not be completed lithe permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or let.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ my person in any manner so at he become subject to the Workers PAID
Compensetionlaweof Califomia..Dete WATER SYSIEMITMATING Date Rettig#
z NOTICE TO APPLICANT:If,after mating this Certificate of Earn o should NEW RESIDENTIAL PLMIL SQ.FT.
itart
ptio de,o s ou TOTAL:
a f/] becme hwithc subjecttothe such re Compenutiis ermisio shall
Labor Code,you must BUILDING FEE
5 forthwith comply with each provisions or this permit shall be deemM revokW: . Q(�
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 z s
I hereby affirm met there is a constitution lending agency for the performmce of
U O the work far which this permit is issued(Sec:3097,Civ.C.) TOTAL: ELECTRIC PEE.. •0
ILLender's Name -
0 U Leaders Address QTY. MECI IANICAL PERMIT FEE PLUMBING FEC
W co 1 unify that I have read Nis application and nate tint the above informers..is MECHANICAL FEE y(
(J. erect.I agree m comply with all city and county ordinances and state laws misting to PERMITISSUANCE •DO a S y
y buildingcommuction,and hereby authodre mt
represeativeste
ofthis city to enr upon the CONSTRUC RRITAX
V shove mantioned propeity far inspection purpoua. ALTER OR ADD TO MECH.
(We)-gree to save,indemnify and keep harmless the City of Cupertino against
imbilairs,judg'insim.emsts index ichmayinanywa eecmeageinat Mal AIR HANDLING UNIT(TO 10,"CFM)
in:�r (��SSSSggqqN, _ of llmlmnbngof his tit.
C 1�0Am !A� AIR HANDLING UNIT(OVER 10,000 CPM)
Signemre of Applicm o to EXIIAUSTIIOOD(W/DUCD
PAID
-Jr HEATING UNIT(TO 100.0W BTU) Date Receipt#
IW-ARDOUS MATERIALS DISCLOSURE
Will the ft Cupernt tinoor u icipai Code, panuto9<oi handlandtellHWdammatnlal HEATING UNIT(OVER IW,000 BT U) TOTAL: Q•�`�
as defined by the Cupertino Municipal Code,Chapter 9.12,and the He1. alth and Safety
Cada Section 25573(gT - ` —
❑Yes 13 No VENTILATION FAN(SINGLE RESID) O
- .: 1 1 - ; I.d ISSUANCE DATE
Will theapplicmtorfuwrebuildin emu BOILER-COME OHP OR IM."BTU)
g he Bay m.Air Quality
cawhichcmit P A D
h.e�a,mdous air conteminanu a defined by the Bey Arae Air Quality Manegem<nt BOILER-COMP(DYER I W,000 BTU) 1N{� 'Ie[]
t� �II ❑)Y 11 No NEWRFSIDENTIALMECH. SQ.FT. SEP mss# IJJ�
I have read the haardous materials requimmenta'umiei Chapter 6.95 of the
California Health k Safety Code.Sections 25505,25533 and 2554.I understand that /�
if the building does not currently have rimmunt,thsat is my responsibi llty lm notify the ^fIY le Ul-Ct11 IIVU
occu nt of the requirements which must be met prim he issuance of a Certificate of
Occupancy. - - s� 1n
Ownse,m ahorvndagent Date TOTAL: ISSUED
OFFIC