25417APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERTINO oICDINc-eLezm[rca
APPLICATION/PERMIT PLUMBING-MECHANICAL
DIVISION ; BUILDING PROJECT IDENTIFICATION -- -
"ENM°'"°. 25417
BSS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
UNIT# LOT#
4�/�NGINEER:
PHONE:
NTRACTOR'S NAME:mNEER:
LIC NO:
A RE S:
I4/\
PHONE:
a4.A k"rib %a"sb'�-S & S..".
4 9 i ?'.
Qa ffi' ,4$' 115 LEC7RIC TPpRMIT y, 1 r. F-BE
:xp
x r. ., �.,BUJ�DIN6 PERMIT INP0
BLDG ELECT - LUMB MECH
PERMIT ISSUANCE
QS3—
❑❑
❑t z
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapler 9(commencing with
APPLIANCES - RESIDENTIAL
JOB
PANELSfar
ti] 00
ta��
r
Sermon 9000) affect. on 3 of the Business and Professions Code, and my license is in
forecanse
Q �
License Cladoffee[.
License Class Lic.#
IIP TO 200 AMPS '
`DESCRIPTION
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ZOyZ
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Dam Contractor
ARCHITECTSDECLARATION
1 understand my plans shall he used ss public records.
201 - 1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
11 �r
II t- L ✓N
_
r'
I �I_� (� ij j,r ryj
II tl� g i
R
$/SQ. FT.
SIGNS ELECTRICAL
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�y <
f30a,F
E+3 W oQe
Cl�m.l
T� }�
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby ,(fits that I am exempt from the Contractors License Lew for the
fallowing reason. (Section 9031.5, Business and Professions Cede: Any city or county
prior to iquisusupennio re mores theappli,improsuch permit orrepaira siigadstate ant
the theapplicantfor statement
permits filLicense
pot islicensed
SPECIAL CIRCUIT/MISC.
z
TEMP. METER OR POLE INST. O
t 1 I\
POWER DEVICES
d4o'
he
that he is nci ng w pursuant to the provisions of the urnLicosa Law (shaper
promnt1. the ContractorsLa
9(commendngwith Section 'l000)of➢ivisinn3of Na Badness and Professions Coda)
TION
I
nw
SWIMMING POOL ELECTRIC 4 kIM
W ern
F 4
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applic t for a permit subjects the applicant to a civil penalty of
OUTLETS - SWITCHES- FfXTURES
m
not mom than five hundred dollars($500).
❑ othew,emfihepropertyeismatmployedon.fard brslhei(sole7044.Bsition,
will dothe wons and the a Business
is
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
TYPE CONSTRUCTION
sr's Llreme Law does not apply to a, owner of
he Contractor License
and Professions Code: The La does ntl apply to con
es the
prtupeny wh n bui ds or improves thereon, and w ho does such work himself or through his
employees, provided that such improvememamc notimended proffered forsale. If,
OCC GROUP
RES. UNITS
TOTAL.
however, the building or improvement s sold within one your ofcompletmn the owner.
budder will have the burden of proving that be did not build or approve for purpose of
, 1 , r , .. r
TY; ai s PLUMBING PERMIT., ,` - PEE>s.•
� a
xk§�< t= yr. -ax
sale).
❑ las owner ofthe t exclusively contracting
ppe.70,am amass el ¢font with licensed conh'aclorvm
@o project (See. osuro Business and y%hoPinfirsbuild find Jove there cais
Licenconstrse
Lice
FLOOD ZONE
APB,
PERMIT ISSUANCE �
cotracts Toroes ent Imytowith arofpropmywhosedpuorimproves Contractor's
who contracts forsuohp )acts with acov,amor(s)licensed pursuant to Contredor'6
hioen6e Law.
ALTER - DRAIN&VENT -WATER (EA)
K PEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reasonBACK
FLOW PROTECT. DEVICE
OIITSIDE L
SANITARY Y N
RECEIPT#
_
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
❑ I hereby affirm that l have a cinificale ofconsent to self-incia, or a cenificale of
Workers'Compensmion insurance or a certified copy thereof (See 3800, Lah C.) which
FIXTURES -PER TRAP
RECEIPT is
PARK FEE Y N
GAS - EA. SYSTEM-1 INC. 4 OUTLETS
(sell employee's wader this permit.
Policy #
RECEIPT #
BUILDING DIVISION PEES
GAS -EA. SYSTEM -OVER 4(EAT
PLANCHF.CK FEE
Company -
❑ Certified copy ishereby famished.
OREASWINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER- SANITARY -STORM EA. 200FT.
ENERGY FEE
This section aeeclum he completed ifthepermit is fortune hundred dollars($100)
orless.)
WATER HEATER W/VENT/ELECTR
I certify that in the performance ofthe work for which This permit is issued. I shall
not employ any person in any matter so as to become subject m the Workers'
PAID
7
Compensation Lawsof California. Date
Applicant
WATER SYSTEM/1'ftEATING
Dow Receipt#
O
z
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL. PCMB. SQ. FT.
TOTAL:
r to
become subject to the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
BUILDING PEE
W O
rr--Err
u" F
Uy a
F.t N
U z
CONSTRUCTION LENDING AGENCY
I herebytrfirm that theta iso exastructiaa leading agenna
cy for the perfmmaeof
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
1 candy that 1 have read This application and state that the above information
cnod constr son. and withyautyaad cepnlyotdiivesofthisetpi moccasin
buildingconstruction.herebspecti np (paws tivesof thiscitysenteropon 0e
the
abo toed property for inspection puBwses.
SEISMIC FEE
TO AL:
ELECTRIC FEE
TY. *."e MECHANICAL PERMIT- } =TBH;;
Q"
PLUMBING FEE
MECHANICAL FP.E
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(we) tgres m siva, indemnify and keep hntmlca6 the City of CLpertino against
Ior:,tie�Y�JSea at. which may in any way a eagains said City
AIR HANDLING UNIT (TO 10,000 CFM)
Tost.andexp9,,cl
inw !q encs s egra kyBo (hits per.
/ /
AIR HANDLING UNIT (OVER 1(1,000 CFM)
v
u A IcamConl clor I Date
EXHAUST HOOD(W/DUCI)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Wil l the applicant or future building occupant store or handle hazardous maternal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health mod Safety
HEATING UNIT (OVER 100,000 BTU)
Code, Section 25532(a)1
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
Will theupplicnnlnr rumrehuildingoccupant use equlpmento(davieee which emit
BOILER - COMP (311P OR 100,001) BTU)
ISSUANCE DATE
BOILER -COMP (OVER 100,000 BTU)
hazadous air commitments as defined by the Bay Area Air Quality Management
District'? -
P A
❑Yes ❑ No
/
M D
NEW RESIDENTIAL MECH. SQ. PT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
Alien g%
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a ennnl, Nm it is my responsibility to notify the
cupsat ofthe requirements which must be met priors issuance of a Certificate of
C
�j t/
Occup ncy.Owner
ISSUED B�y
or a,lhorized ages Date
TOTAL:
OFFICE