25316 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
B - RI AI. PERMIT NO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUNKING-MECHANICAL
BUILDING DIVISION 6UILDING PROTECT IDENTIFICATION 25316
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITALDATE
22k4ee �,2. UNIT# LOT#
OWNERS NAME: I k. e-WePHONE: CON OR'S NAME: LIC NO:
CJL N/C CON TROL#
• RCHITECT/ENCINEER: LICNO: ADD S: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
c E: QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE BLDG ELECT0U ME❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
paz Thereby affirm fhatlam lioensed underpfvvislonsof Chapmr9(commencing with
woo Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
E full force and effect.
aU
<Z, License Class Llc.# UPT02MAMPS
ut�6 y Date Commmor 201-1000 AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
z00 ARCHITECTS DECLARATION OVER IOW AMPS
b z-,C I understand my plans shall be used as public records.
y SIGNS ELECTRICAL
Licensed Professional
9a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. E D I N
KOaU 1 hereby affirm ntrac
that I am exempt from the Commutes License Law for the r
<V 3 C)y following reason(Section 3031.5,Business and Professions Code:Any lily or county TEMP.METER OR POLE INST, p p
O¢ which requires a permit to construct,alter,improve,demolish,or repair any structure I' II
N� prior its issuance,also requires the applicant forsuch planate,file satiated statement POWER DEVICES �,J
4 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
M 9(commencing with Section 7000 of Division 3 ofthe Business and Professions Cade) SWIMMINGPOOLELECTRIC VALU ION
61�w or that he is exemph therefrom antl tM1e M1asis for Ne alleged exemption.AayviolatimoF OUTLETS-SWITCHES-FIXNR
Y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
of thanfve hundred dollars($500) NEWRFSIDENTALELECIR _SQ.Ff. STORIES TYMCONSTRUCTION
, sownerofineproperty,ormyemployecswiNwagesastheirsolecompensatim,
y _ ework,zndthe structure is not intendedoreffired formle(See.7094,13minces
a Formations Code:The Committees License Use does not apply to an owner of
ppertywhobuildsorimproves thereonmd whodues such work himselforduoughhis OCC.GROUP RES.UNITS
o nemployees,providedthat such improvements are notimendedoroffered forsam.If,
h wever.Ne building orimprovement is soldwithin one yaarofcompletlon,themener- TOTAL:
b 'Ider will have the burden of proving that he did not build or improve for purpose of
s
a ')' PLUMBING PERMIT FEE FLOODZONE APN
❑ n
I,as rofthepropeny.amexclusivelycomractingwithlicensedconvacmrsm QTY.
construct theprojem(Seo.7044,Business and Professions CWcJ The Coovamors
Liemse Lawdoesnof apply to an menerofpropenywhobuilds orimproves thereon.=it PERMITISSUANCP
whommmns fimmehprojecte withacontractods)IicensW pursuant to the Convectors ALTER-GRAIN&VENT-WATER(EA) V FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason OUTSIDE
BACK FLOW PROTECT.DEVICE. E
SANITARY YN
Owner Dare DRAINS-FLOOR,ROOF,AMA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Iherebyafrn.tMtlhaveacenificamofconsenttoself-imum,oracertificateof FIXTURES-PER TRAPRECEIPT#
Workers'Compensation Insurance or o cenified copy thereof(See.3800,Lab C.)which PARKFEE Y N
RECEIPT#
covers all employee's under.this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenified copy is fled with the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING PEE
CF,RTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or less.)
I cenifythat in the performance office work for which this permit is issued,I shall WATER HEATER W/VENT/ELECPR
not employ any person in any manner,an as to become subject to the Worker% PAID
Compensation Lawsof Califomie, Date WATER SYSTEMITREATING Date Receipt#
Q z Applicant
z0 NOTICE TO APPLICANT:If,after making ibis Certificate of8xemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
DObecome subjecno the Weakera Compensation provisions of the Labor Code,you must
5 forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
Wti
(] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of T ELECTRIC FEE
U O the work for which this Permit is issued(Sea 3097,Civ.C.)
4. Lenders Name PLUMBING FEE
0 F Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that I hove read this application end state that the above information is MECHANICAL FEE
>' LkI correct.Iugrec mcomply with ell city and counry ordinances and smm laws relating to PERMIT ISSUANCE
F-' building conioned.n,and herebyauthomerepumminotwesofthis city to emeruponthe CONSTRUCTION TAX
Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
hidaliu dgments,costs and expenses which arayin any way accrue against mid City AIR HANDLING UNIT(TO 10,W0 CFM)
o gxence of IM1e gmming mf Nis m it.
AIR HANDLING UNIT(OVER 10,000 CFM)
fgnature of Applicant/Cu rano, a Date a EXHAUST HOOD OVDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE?/�y + HEATING UNIT ITO 100,000 BTU) Date Receipt#
Will the applicant or future building oecupmt store or handle? do materiel HEATING UNIT(OVER 100,000 BTU) L
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 25532(x)7
❑Yes IJ No VENTILATION PAN(SINGLE REBID)
ISSUANCE DATE
Will theapplineram atuebuildingocmpant useequipmtmamilviceseehichemit BOILER-COMP(3HP OR IOOpW RUJ)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10h,000 BTU)
DistncIT 11 Yea 11 No
No NEW RESIDENTIAL MECH. SQ.Ff. P
1 have read the hazardous materials oupt5505,,25533 under 34,Chaptertun understand
of the ppB fryfA py 'T
ifmc uil Health s Safety Cade,Sections 25505,25533 and 25534. 1 understand II 'I,VwW7�f/��]/�//1
w thebullof t docs not menta ly have a must
be met it is my reuance of a li motify the
occupant of the requirements which must be met prior to issuance of a Cenif¢am
Occupancy.
Owner or authorized agent Date " TOTAL: ISSUED BY:
OFFlUt