25762 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBt7m'1.-.1lCWAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL, r) `�C OLr)
BUILDING DIVISION 6UILUINGPROJECT IDENTIFICATION GJ
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL TE
10 'AL DA
J C712 LOT is
qfFfUS PHONE: co]6LT;J NALIC NO: 111 J
eAer1 NIC CONTROL 4
�IFCONTA�:
RCIITIECf/ENGINEEIU LIC NO: ADDRESS:
PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTIONE
mmzrm thotlam li<rnsed underprovisionsof Chapter9(commencingwith+�00Division 3afthe Business and Rofcssiv Codeand my license is in PANELS
aUFct.ZWa,1 ^1 Lic.p 4 UP T02(q AMPS
yQy to Contractor T+-'� 201-1000 AMPS
�Oy> ARCHITECTS DECLARATION OVER 11100 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
OZ-0 1 understand my plans shall be toed as public reccoN.
P=. != SIGNS ELECTRICAL fn
6wxQ Licensed Rofessional OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. r� '
aaXowu I hereby affirm that I am exempt from the Commerce,License law for the
cal� �m following reason,(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR MOLE INST,
P F1
w y 2 wM1irt requires n permit re construct,alter,plic Improve,demolish,or repair any sstructuretatement
L /�����
y}2 priormit issuance,also requires the applicant for such pemriuo file aligned statement POWER DEVICES t
W_G C that he is licensed pursuant to Ne provisions of the Contractors License Law(Chapter
ddb DA
9(commencing NScaion]000)of Division3ofthe Businew and Rvfcssions Cotic SWIMMING POOL ELECTRIC
Xo�' (co gwi ) ALUATION
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURCS
�7aSection 7031.5 by any applicant for a pvocit subjects the applicant m u civil Penalty of
5S0 not morothvn five hundred dollars($500). NEW RESIDENTIALELECIR _SQ.IT.
WF� ❑ L as Owneroftheproperty,ormyemployeeswiNwage cradle(Sce.compensation, STORIES TYPE CONS'IRUCTIOh
n3— will dothe wo Profession,ane the scrMe Corti not is Lic a se La ado s not apply t sur Business
and erywh Codldsor improves
Contractors License law does not apply to an owner of
property who buildsor improvesch improand whoaces such work himselfed through his
own employees,lding cdNmevemenpnrvld within not eyear feempRured fiathe owner, DCC GROUP RES.UNIy'S
however,the building or improvement is sold within one year ofcoproose far the owner-
buiidcrwill have the burden of pmving that he did not build or improve for putpou of
sale.).
❑ I,asownerofthepropeny,amexclusivelycontractingwiNEcen.e contraaorsro QTY. PLUMBING PERMIT FEE IT.00D ZONE APN
construct the project(Sec.7044.Business and Professions Code:)The Contractor's
Licca<cl.uw Juesnnt uPMly to un ownerol property who M1ui Ws orimprovevherron,and PERMIT ISSUANCE
who contracts
N
forsuch injects wiacontmemgs)licrnsed pursuant a the Contractor
License Ww. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason FLOW PROTECT. FEES
RACK OW PROTECT.DEVICE SANITARY YN
Owner Date DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOL'TAX YN
❑ Thereby affirm that lhave aartifice¢of canxm mxlf-insure.or eocnificate of FIXTURES-PER TRAP RECEIPT#
WorkeriCmmpensarion lrtsumnceon cenifiedcopy Nercop$ec.3800,Lab C.)which PARK FEE Y N
coven all employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION IBES
Company
❑ Cenified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is fled with Ne city inspcaion division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS FEECOMPENSATION INSURANCE
(This section need not he completed ifthe permit is befonc hundred dollars($100)
or less.) SEWER-SANITARY-STORM FA.2WIT. ENERGY FEE
leartifyfli mine psrfsm anceof@e work(orwhich thi,permit isissinaLl shall WATER HEATER WIV N- /ELECTR
not employ any .no in any rearnme,s to be ryp rob'ect to the Workers' PAID
Com t^miomgwaof lifoma. Date WATER SYSTEMfl BATING Uatc Receipt is
O AM cu t t��4411 C t
Z v,,,, I'IGE TO APPLICANT If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
F esubject m the Workers Cmialmmion provisionsofthe Labor Code,you must
I fa mwith comply with such provisions rn this permit shall be deemed revoked. BUILDING ME
(� CONSTRUCTION LENDING AGENCY SEISMIC FEL'
Z I hexhy affirm that he.is a construction lending agency for the performance of
U O the work for which this permit is issued(Sect.3EO,Co.C.) TOTAL: ELECTRIC FEE
Lenders Name
V.
LendersO U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have read this application and state that the above information is
coral. I agree to comply with all city and county adimince,andslne luwsrelating to PERMIT ISSUANCE. MECI IANICAL FEE
F-' building construction.and hereby immunize representatives of this city to enter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree tat save,indemnify and keep harmless the City of Cupenino against
Iiabilitics,judgments.costaand expenses which may in any way seems,against said City AIR HANDLING UNIT(TO 10,000 CFM)
e of the granting of t mrit.
r- 11 �1C9 AIR HANDLING UNIT(OVER IgWOCFM)
Signature of Applicant/Convector Do. MIA UST HOOD(W/DUCI
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Date Receipt b
Will the applicant or future building occupant store or handle M1avardaus material
as defined by the Cupertino Municipal Cotie,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 25532hr?
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
_ Will NeuPMlicannaluwrchuilding occupant useeyuipmemordevices whichemit
BOILER-COMP(]IIP OR IM."BTU) ISSUANCE DATE.
uuJnas air contaminants as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Water?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,FT.
Lbuilding
read the hazardous materials rcyairemcros under Chapter 6.95 of the ,�"8 A
ga I o ffi of cur CWy have oto ant.th 25533 and sponsi I ityJcrstand Nat g'9g Jces not curtenrly havcatenanr,Nm it ixmy rcsponsibilityronotifythe requirements which must M met prior m issuance of a Certificate olhonuJ agent Uamr:
TOTAL: ISSUED BY:
OFFICE