25900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - -F- DUCAL PHRMI'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25900
BUILDING PROJECT IUF.NTIFICATITIN
BUILDING ADDRESS: SANITARY NO. AAPPIICA'LON SUBMITTAL DATE
• \ J ' % s hEOL �� UNIT# LOT s-2-6-0
�
OWNERS NAKJh:: PHONE:�y CONPR E: LIC NO: NIC CONTROL#
r I OR'SNA
—S
I�ARCHITECT/ENGINE—ER: LIC NO: AIDRESS ❑
CONTACT: (,�� PHONE: 5( BUILDING PERMIT INFO
�HP /0/I QTY. ELECTRIC PERMIT FEE
J0), PERMIT ISSUANCE
BLDG ELECT PLUMB MECH
❑ 1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-R&SIDP.NTIAL JOB DESCRIPTION
p00 Ihereby 7")affimUha[l 3 ofth Bussed iness
and provisions Code,and
(commencing with
tx1�W fall Section 7")and e f Division J of lM1e Business and Professions Code.and my license is in ppNE15 /I ���
C fEJ full force and effect J
zW License Class Lic.# UP T020 AMPS I
V, Data Connote 201-100 AMPS
Z FON2 ARCHITECTS DECLARATION OVER IfgXIAMPS SQ.ff.FLOOR AREA $ISQ.FT.
OZ�❑ l understand my plans shall be used as Public records.
F.y, J SIGNS ELECTRICAL.
-IY Licensed Pndessional
0. Q
OWNER-BUILDER DECLARATION SPECIALCIR IT/ 1�>i
yx0 1 hereby affirm that 1 am exempt from the Contractor's Lwene Law for the
t+s3 v.y following reason. Business and Professions Code:Any city or county 'TEMP.METER OR LEI S .� r �" l`s t-� •¢ n "^ +a
which requires a pemsio to conswek eller,improve,demolish,mot any et..cam FEWER DEVICES v pF1
Eys�To prior..slisommcensed pursuant to the theappivisios of the CroPermit lorile a LicesigLa stamment ) Ji
Wf Qp that heisncingwpursuanuothep..visiomof the Conlmetess and Pro Lawns Coder
A SWIMMING 'OL ELF.CfRIC yplyngpN
LLo�' 9(commencing with Section 71100)of Oivision3nf the Business and Professions Code)
� Its
2,, or that he is exempuherefrom and the bosis for the ellegeJ exemption.Any violation of
Section 7031.5 by any applicant for.penoth snt OUTLETS-SCHFS-
Ob
ubjects the applicato a civil penalty of O�
not marc than five hundred dollars($50).
O NEW RFSIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
m ❑ I,uesoork.And the
sumetweI,net
eadialwithwaalfor Wei Sec.compensation,
a3— will dothewons Code The Cureia room iccome ofwdoes nota ply 9044,Bus
andProax
Processions Codr.The Convectors License Law uses or apply to an owner of
pmpcnywho builds orimproves thereon,and who does such wnrk himulfathmughhi1 OCC.GROUP RES.UNIT'S
howemployebuildi gtor i that inch imp..vcmcros are one
yew m d mpletired for mvax L
however,the buildingor improvement is sold within ane yearM completion,the owner-
builder will have the burden of proving that he did not build or improve for purpou of
aly). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
�� roftheproperty4,Businesis and rifassngwi[hdn)Tdconvactonm
Lima the project(Sec.9044,Business roti ywholians Cale)The Conear,ans PERMIT ISSUANCE
Liknm Luwdoexnot apply tounownero(property whabuilds nrimprnvw[hereon,and
w4lecommas far such projects with a convactorfs)licensed punuan[to the Contractors
` Liewas,Law. ALTFiR-DRAIN&VENT-WATER(EA) FEE SUMMARY
PER
❑ 1 em exempt under Sec. ,D&P C for this mason PACK FLOW PROTECT.DF.V ICE OUTSIDE
SANITARY Y N
Owner Date RECEIPT.
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ Ihertby uffvm Nmlheveacenifi<era ofconumto ulr-imam,orecenificete of pIXTUppS.PER TRAP RECEIPT#
Workers'Compensation hoornmceoracenified copy themf(Sec.3800,Luh C.)which PARK IEE Y N
coven all employee's under this permitGAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cendiedr.pyishesebyhorkhed.
❑ Certified copy is filed with the city inspection division. GREASEANDUSq'BE WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseaionneedumbecmaplemn ifthepemtitisforonelvndrWdo1lars(E10) SEWER-SANITARY-STORM EA.30FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WIVENT/ELECTR
not employ any person in any manner so as to became subject to the Workers PAID
Compensders Lawsof California. Data WATER SYSTEMfrREATING Date Receipt
ZZ Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,Ff, TOTAL:
became subject o the Workers Comparemicn provisions of the Labor Code,you must
(3: forthwith comply with such...visions.,,his permit shut[he deemed revoked. BUILDING FEE
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE `
Z Ihachyafprm that he.iso construed.leading agency for the performance mf TOTAL: ELECTRIC FEF.
U O the work for which this permit is issued(See.309'!,Civ.C)
4. Imders Name PLUMBING FEE
0 F Landers Address QTY, MECHANICAL PERMIT' FEE
U I senify that I have read this application and sate the Ne above mmoomion is MECHANICAL FEE
7" W
correct I agree w comply with all city and county ordinances and state laws relating to PERMITISSUANCE
V building construction,andhereby authodft
ae mpresentativesohis city loaner upon Ne CONSTRUCTION TAX
i brave-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmems,mstsmdexpenus which may in any wsyac eeBit stramd Chy AIR HANDLING UNITHO 10,00CFM)
enc¢of ting of this permit.
m � � AIR HANDLING UNIT(OVER 10,00s)CFM)
Slg toren PPemVCmwmctor me EXHAUST HOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO EXIJJ(111 BTU) Date Receipt It
Will the applicant or future building occupant store or handle hesardom material HEATING UNIT(OVER 100.00 BTU) AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,mrd the Health and Safety
Code,Section 2553200? VENT ILATION FAN(SINGLE RISIU)
❑Yes ❑No
ISSUANCE DATE
Will the upp[icant orfuumbuilding occupant macquipmenl ordevices which emit BOILER-COMPLIHPOR 100,000 BTU)
.ha,adoor air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 10,000 BTU) P A I D
District?
11Yet ❑No NEW RESIDENTIALMECH. SQ.FT.
1 have read the hansom.mrsteriak requirements under Chapter 6.95 of the Lor® 1
California Health&Safety Cale,Sections 2.5505,25533 and 25534.I understand that T�/V1t
if the building does not currently have a boom,o ,that ii is my respomibility to notify the rj'•• W CHI
occupant writhe requirements which mus[be,met prior m issume.of a Certificaa of
Occupancy.
Owner or authorised agent Dae TOTAL: ISSUED BY:
OFFICE