25111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPESION APPLICATION/PERMIT PERMIT No. �,
BUILDING DIVISION PLUMBING�MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDDRESS. ■/�� SANITARY NO. APPP�LICATIONSUBMITTTALLDDATE
)'
101,11 1—itJ6kV1Y* Mr• UNIT# LOT#
ERSNAME;L' . NP ONZ$A OR'S NA LIC NO: SEE CONTROL# V
€, Y� Ae..l 1, T�otiw W !V`�
< SRCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
N ayrl� _ BLDG ELECT PLUMB MECH
W�•�V PERMIT ISSUANCE I�TN/I IrTJ�II/`
LICENSED CONTRACTORnderpmSDnCofCh TION APPLIANCESRESIDENTIALES RIPTIOC N I!
OCZ lhereby7M)of affirm mor 3 of
sed Business
and Professions
Code,and mmcoense with
m00 Section 9000)ofetDivision 3 of the Business and Professions Codc,and my license is in PANELS fI
X W' roll roe and effect.
QF Z W License Class Lic.# UP TO 200 AMPS
Fr D h Date Commerce 201-1000 AMP$ S .FX FLOOR AREA $/SQ.FT.
OOh ARCHITECTS DECLARATION - OVER 1000 AMPS
O 2,. 1 understand my plena shall be used as public records.
P:cox F W SIGNS ELECTRICAL
<:�� Licensed ProfeVional
E: laid OWNER-BUILDER DECLARATION SPECIAL CIRCU[T/MISC.
01
X ter I hereby off.Nat 1 an exempt from the Conmaomr's License Law for the
W 3 LFr m following reason.(Section 70315.Business and Professions Code Any city or county, TEMP.METER OR PULE INST.
which requires a froman m construct,cher,improve,demolish,o,repair any stmrare
prior its isscance,irlsom uiresdan applicant fim uch pertNlta file aslgnedraterrom POWER DEVICES
N a'qp that he is licensed pursuant to the provisions of the Contractors License Law(Chapter SWIMMING PoOLELECTRIC
n.Xo� 9(commene;ng,ch Seen..700m)of Division 3 of Business and Professions Cade) VALU�MQii
play or that he is exempt and the basis for the alleged exemption.Any violation of �V
E.y YSection 9031.5 by any applicant for a permit subjects the applicantroacivil penalty of OUTLETS-SWITCHES-FIXTURES
�EQ O not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR S
KF_0 ❑ I,asownerofthepropeny,ormyemployeeswithwMesaetheirsolecompensation, Q'FT. STORIES TYPE CONSTRUCTION
a3222 will do the work,and thesvuctnre e,not intended oroffered forsale(Sec9fW4,Business
and Professions Cade:The Contractors License Law does not apply to an owner of
property who builds or improv as thereon,and who does such work himselfor through his
own employees,provided that such improvements recommended oroffered for sale If, OCCGROUP RES.UNITS
however,the building or improvement is sold within one yearofcompletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
❑ 1,us ownendlne pmpery,amexdusivelycontraaingwiN Gamed convectorsm QTY. - PLUMBING PERMIT FEE FLOOD LONE APN
onstma the prier,tSec.7044,Business and Professions Code:)The Ctintracmr's
License Law doesnot apply to an ownerofpropery whobuildsorimpmves hereon,and PERMIT ISSUANCE
who contracts forsucn projects with acommewds)licensed pursuant o the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under See. ,B&PC for this reason OUTSIDE FEES
{{ BACK FLOW PROTECT.DEVICE.
SANITARY Y N
Owner Date I RECEIPT#
z DRAINS-FLOOR.ROOF, COND.ii( WORKMAN
COMPENSATION SCHOOL TAX Y N
Wo cmhereby Compensation
thatInsurance
offornseent to 380 .Lab C.)which RBC811'I'#
FIXTURES-PER TRAP
1Workcrs Compansacionineurenx oracerIDed copy chemo((Sec.38IX1,Lab C.)which PARK PEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
C❑ Certified copy is hereby f roolard.ompany GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Certified copy is fled with lire city inspection division. GREASE,/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbe completed drive permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of Its,weak for which this permit is issued,Ideal] WATER HEATER W/VENT/ELECTR
not employ any person in any marmer so.to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEM/IREATING Date Receipt#
� Z Appbcanl
Z2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FL TOTAL
�
become subject to the Worker's Compensation provisions of the Labor Code,you must
7 forthwith comply with such provisions ar this permit shall be deemN revoked. ^ I� BUILDING FEE
L1�
� r CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I hereby affirm that them is a commission lending agency for the performance of
Q the work for which this permit is issued(See.JOST,Civ.C.) T T ELECTRIC FEE
Lender's Name
OF^ Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 eerify that 1 have read this application and state that the above information is
W corer.lagramcomply with all ciry'end county ordinances and state laws relatingm PERMIT ISSUANCE MECHANICAL FEE
(• a building construction,and hereby audmrizerepruemativesofthis city to armrtiam We
U Z above-mentioned rt for ins tion ALTER OR ADD TO MECH. CONSTRUCTION TAX
grape y pec purposes.
(We)agree to save,indemnify cod keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way acme agaustsaid City AIR HANDLING UNIT'(T010,000 CFM)
in con 'j" uggeof the gmntiog (chis n.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of IVItearrAfsancessiber ace EXHAUST HOOD(W/DUCP) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT G 0100,000 BTU) Dam Receipt#
Will the applicant or future building xeupadc sfom or handle hazardous material HEATING UNIT(OVER 100,000 BT'll) O
as defined by the Cuperino Municipal Cade,Chapter 9.12,and the Health and Safety
k.
Code.Section 25532(a)P VENTILATION FAN 0 yes 11 No (SINGLE RESID)
ISSUANCE DAT
YS' BOILER-COMP QHP OR 100,000 BTIO
All
� Willth pplcanl f t tib ddingoccupant use equipmentordevlaswhrhemit
bBard mmin I a d fined by Ire Buy Ama Air Quality Management BOILER-COMP(OVER 100,000 BTU) /9pD
D'ia 1" /i
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FIL E ^yo
I have readHealth
the f ty Code,
materials requirements under Chapter understand
of the •�4 � _
California Health&Safely Code,Sermons 25505,25533 itis and 25534.1 understand thr `r V3
occupabuilding edoes
requirements
ly have a whihmustnove metltsmyssuance of itywnotify the
of —
xupant Of IM1e requirunents wh'mh must rte met prior to issuance of a Certificate of
Oecupyncy. '"Ci7111VU
Owner or authorized agent Date TOTAL: ISSUED BY: