25695 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOput, .- - L. PERMIT"°. 25695
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:P� SANITARY NO. APPLICATIONSUBMITTALDATE
LOT
OWNERS A E: PHONE:JA) BAC 'SNA E: ./'� LIC NO:
N/C CONTROL#
GINEER: LIC NO: ADDRESS:
"TACT: PHONE: .x k ''y •BUILDING PERMIT INPO
QTY,,,; LECIRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMITISSUANCR ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTA. JOB DESCRIPTION
yy I hereby affirm that l sat licensed andrpmvisionsofC pter9(commmcingwith
00 full fame
eandefDivision Sof Ne Business and Professions Cade,and my license is in ppfQpl,g �
q V full force and effect.
Z Licence Clues Lic.p UP T0200AMPS
y 6 y Date14 Mail Convnemr 201-1000 AMPS
z�yaARCHITECFSDECLARATION OVER 1000 AMPS SQ,Fr.PLOORAREA, $/SQ.FT.
CZ-0 l understand my plans shall h used as public record.
P 4 V SIGNS HLECTRICAL
6y � Llmnud Pmfaasional
4ym6 OWNER-BUILDER DECLARATION SPECIALCIRC'UTJMSC.
O a U 1 hereby affirm that 1 an exempt from the Contractor's License Law for the
W 3 O y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
(:f5 y which requires a permit m construct,alenq improve,demolish,m repair any air ..
ay}� prior in its issuance,also requires Ne applicant forsuch pemut to file a signed sentiment POWER DEVICES
ap Oy lhut he is licensed moment to the provisions of the Convector's License Law(Chapter
da OLL 9(commencing with Section]000)of Division Sof the Business and Pmfessiov Code) SWIMMING POOL ELECTRIC VALUATION
^,y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES I
t—Z_G Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of
nm mom than five hundred dollars(5500).
t�0 NEWRESIDENTIALELECTR _5 .FT. TYPE CONSTRUCTION
Lo ❑ Lnownk,md esnct misnotmpindm ar ffea ormic(adecompenmtion,
d will dothesicas CdNuwnumtactor is Leese La does
not
in an Burrow
and Professions Cede:The w.thme f.License Law data not apply to an owner of
ownpropenywyces,pdsorimprovesch impwendweddoessuinten oroffndforee.If,
employees,pmvidedrhet such improvcmentsatenotimm�ded oro!femdforsale.If, EIPN
however.the building orimpmvcment is mid within oneyearof completion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of _ P❑ I,nowneroftheMopeny,amexclasivelycomnctingwithlimaed.nn lonre QTY. LUMBING PERMIT PEE FLooD oNE
o motet the project(Sec.7040,Busincsa and Professions Cale:)The Convector's
License Lawdoes not applyto a ownerofpropeny whobuildscrimprovea Merton,and PERMIT ISSUANCE
who contracts fmsuch prefects with aconninums)licensed pursuwumhe Contractors
Licanm Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reamer BACK FLOW PROTECT.DEVICE IDH
SANITARY Y N
Owner Dere RECEIPT#
DRAINS-FLOOR.ROOF,ARFA,COND.
WORKMAN COMPHNte ofO ntmwlfATION SCHOOL TAX V N
❑ lhembyer,'Cm Niemth,Inmreem.rcmeofcovemmm(Sce.3,m L.b C.)ateofwhich FIXTURES-PHIt'IRAP RECEIVfa
Workers Cnmpenansionlnsuranceoracenifmtl copy thereof(Sec.3800,Lab CJ which PARK FEE YN
cove.all employees undr this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-P.A.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Candied ropy is hereby famished.
❑ Cenifcdeopy is filedwiN the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS ME
COMPENSATION INSURANCE
(This section need nosh completed ifthepermit is forone hundred dollars(SIM) SEWER-SANITARY-STORM EA.20)FT. ENERGY FEE
or leu.)
I vanity that in the performance of the wed for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any Wanner m as m become subject m the Workers' PAID
Companation Lawsof California. Date WATER SYSTEM/TREATING Data Receipt#
Q z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
fop become subject to the Worker's Compenm0on provisions of the labor Code,you must
; forthwith comply with such provisions or this panni,shill be rimmed revoked. BUILDING FRE
CLISEISMIC FEE
Q CONSTRUCTIONLENDING AGENCY
I hereby which
t that them is amed!(S.3 lending agency for the performance of
U O pc�i TOTAL: ELECTRIC FF;E
the wad for which this t Is issued(Sec.309],Civ.CJ
I emlee's N
U ame
IsndAdd..s Add.. QTY.',' � ' MECHANICAL PERMIT FEC PLUMBING FEE
{ I mnnate ify that 1 have read this application and Wt the above information is
correct, I agree to comply with all city and county onlinances and sum laws relating to PERMIT ISSUANCE MECHANICAL FEE
p" Wilding convection,and hereby authorim represanutives ofthisciry toenter upon the
V 7 above-mentioned properly for inspection purpoaea. ALTERORADDTOMECH. CONSTRUCTION TAX
O (We)agree to save,indemnify and keep harmleu the City of Cupcnino ageiat
]iabilams,ni g u,6ts and expenses whichanyrnanyway accrue agaia,sm,City AIRHANDLING UNUTO I0,000CFM)
On conequen grantingof permit.
IYAW
AIR HANDLING UNIT(OVER 10,000 CFM)
Snsre of Apphcer onormtor ^
mData EXHAUSTHOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,000 BTU) Data RmeiptIs
Will the applicant or furore building..poor horn or handle hazardous materiel HEATING UNIT(OVER 100,!100 RTU) QTAu
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)7 VENTILATION FAN(SINGLE RMID) �_
❑Yea ❑No
' ISSUANCE DATE
Willtheapplicanmrfumrcbuildingaccupant useequipmammd,0ceswbiehmrR BOILER-COW OR lOgOW BTU)
hamNous air commandments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,"BTU)
District?
❑Yes ON. NEWRESIDENTIALMECH. SQ.FT. m A B D
y Y M
I have reed the Safety
Ca ux mamrids requirements under Chapter understood
of the
Cilie buil ing do&Sefery Code,Section 25505,25533 it
and 25534.I undenennd that
iccupanilofineres not quiremntswhicly veama,met ii is mymapnceoilitymnfica the NO
V
occupant of Ne requirements which must h ran prim to issuance of a Ccnificau of v
Occupancy. /a
Ownermanthorizedogem Dam T ISSUED BIYI� fplw -
OF