25581 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUR:b1NC-FI:FCI7HCAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. 25581 IIUILDINC.PNOJBCI'IHEN'i'IFTCA'i5 Q
'ION JJ 1
BUILDIN��G'\A/�DDy�RESS: ` ` 1 SANITARY NO, APPLICATION SUBMITTAL DATE
Vs/tO � W UNIT# LOT as
OWyLRS M' !� PHO 1 CO T NA i1{G L NIC CON TROL#
_ ROUTECT/ENGINEIiR: (� LIC NO: ADDRESS: I • O v ❑
:ONT'ACT: PHONE: K
QTY. ELECTRIC PERMIT FET: BUILDING PERMIT INFO
811 ELECT PLUMB MECH
PERMIT ISSUANCE PLUMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Iherebyaffirmthm l omlicensMunderprovisionsofaapser9(commcncingwith
q00 Section 7000)of Division 3.f the Business and Profusions Code,mainly license is in PANELS /}�'\'
6E• full force and effect. IIPTO 200AMPS y/ ePT;)5
ZW License Lie.# W\
w,W Gate Contractor 201-1000 AMPS SQ.Pf.
yZ, ARCHITECFSDECIARATION OVER 1000 AMPS FLOOR AREA E/SQ.FT.
AMO PS
I understand my plicas shall be used as public records.
�y � SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCURIMISC,
4'C) , I hereby affirm that 1 sum exempt from the Commences License Law for the
W'a,, following meson.(Section 7031.5.Business and Professions Code:Any city or county TEMP.MITER OR POLE INST.
F- 0 wM1ich requires a permit m constmet,eller,improve,demolish.or rtpa'v any ctmemm
}� prior m its issuance,uhmoNuims do applicant(o much pcmnitm filaasignedsutement POWER DEVICES
cep that he is licensed purauam m the provisions of the Couremolc License Lew(Chapter
el. 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMMG POOL ELECTRIC VALUATION
ty�y or that he is exempt hercfrnm and the basis far theuN
llagad exemption.Any violation of OUTLETS
-SWITCHES-FIXTURES I ® 8
a Section 7031.5 by any applicant for a permit subjects the applicant a civi l penalty of VV
nor mom than five hundred dollars(5500). NEW RESIDENTIAL ELECB _SQ.
a3$ ❑ i,mownerofthepropeny,ormycmplomswiihwagcsas Neirsolecompevation, P1 S '1'Y ECONSTRUCf10N
wil l do the work,laid the avucture isnot intended oroffered for We(Sec.7044,Business 0 I— R
cad Profusions Cade:'rne Contractor's Luau law dose not apply to an..or of
pmparty w ho b u ilds or improves thereon,sad who does such woh Nmxlf onlwugh his
ownemployees,pmvidedthatsuchimpmvementsmnotintendedoroffemdforsle.If, 4-na RES.UNITS
however,the bandingor improvement is sold wid inoneycurofcompletion,the owner- L: _
builder will have the burden of proving that he did not build or improve for purpose of
a I0.).
EI1,usownerofthepmpeny,amexclusivelyconbactingwithlicensedcont torso QTY. PLUMBING PERMIT FEF, FLOODZONE APN
construct the project(Sec.7044,Business end Professions Code:)The Contractors
Licanu Law dcesnot apply manownerofpropeny whobuildsorimpmves thereon,and PERMIT ISSUANCE
VIM
whocomactsforsuch projects with o comuactiond licansed puram uothe Corbel
Licaue law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 tan exempt dada Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE arrE PE SANITARY Y L N
Owner Date DRAINS-MOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm rhntlhove ecerti0cate of cnnum mself-insure,ore certifiwm of FIX'T'URES-PER TRAP RECEIPI'p
Workers'Compcnsmion lnsmanceora cenified copy thereof(See.3900.Lab C.)which PARK PER Y N
covers all employee's under this permit. GAS-PA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
I)nllcy o BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑�Caddied copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASPpNDUSTRL WASTE INTERCEPTOR GRADING FEE
=„ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section need not becompleted ifthe permit is foronehundred dollars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
colas.)
I certify that in Ne afomaince of the work for which this permit is iuued,I soon WATER HEATER W/VENT/ELECTR
not employ any parwn in any mama,sec as m become subject to the Wall PAID
C.unKro ltharlaweef Celifomia. Data WATER SYSTEM/IREATING Dam Receipt#
Q z Applicant
z0 NOTICE TO APPLICANT:If,after making this Cart of Exemption,you should NEW RES IDENTIAL PLMB. SQ.FT. TOTAL:
r•. fq become subject to the Worker's Compensation provisions of the Labor Code,you must
•�� •fnahwiih comply with such provisions or this permit shall be deemed revoked BUILDING FEE
yQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm Net Nem is a concoction lending agmcy for the performance of
U O the work for which Nis permit is issued(St .3097,Civ.C.) ELECTRIC FEL
Lender's Name PLUMBING FEE
Q U
lenders Aress QTY. MECHANICAL PERMIT FEF:
I coldly that 1 have read this application and mate that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildingeonstruction.and hereby authorize representatives ofthis city memcruponthe CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap harat Ne City of Cupertino against
liabilitiesJudgmenta,costs end expenses whicheray in any woyecemeagainat void City AIR HANDLING UNIT TO 10,000 CFM)
in consequen N timgofthi rmtt.
AIR HANDLING UNIT(OVER 10.00)CFM)
Slgnm of pplicwUCon D / '_ Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00,b BTU) Date Receipt p
Will the applicant or future building occupant store or handle hazardous material ]MATING UNIT(OVER 100,000 BTl17 T L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Cade,Section 25532(e)7 VENTILATION PAN(SINGLE RPSID)AM V__❑Y. ❑No
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
Will thespplicanmrfuwrt builthngeccupentuseeyuipmem ordevim whichemit ,p
hamomus air comuminaH as ndefined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P A 9
Diauic@
❑Yes ❑No NEW RESIDENTIAL MECIJ. SQ.FT. Q(�
I have read the hazardous materials requirements under Chapter 6.95 of the Mr 1993
California Health&Safety Code,Sections 25505,25533 sand 25534.1 understand that
if the building
erenot currtn0yhave atenant,restitismy responsibilityurancof
enotifythe CITY Uh CUI-cn IawIJ�
nccupam of the rtquiremenu which must he met prior m issuance of a Certificate of
Occupancy.
Owner or atibleiud agent Dme TOTAL: ISSUED
OFFICE