25647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' CITY OF CUPERTINO HUIL ELECTRICALPERMIT No.
APPLICATION/PERMIT PLUMBING.
MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 25647
BUILDING ADDRESS: ,./ SANITARY NO. APPLICATIONSUBBM•ITTALDATE
UNIT Ji LOT# �LJ
OWNF;RS NAME: , IL1 Rini,/
PHONE: CONTRACTOR'g NAME NO
J� �CNO: NA: CONTROLL##
�l•
�ARCHITECT/ENGINEER: L LIC NO: ADDRESS: r( �O �
ate; �1
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ELECT PLUMB MECH
PERMIT ISSUANCE 0 El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
p q�Z I herebyaffirmthat l am licamadunderpmO,iom.fChaplar9(commencing with
zo❑ Section 7000)of Division 3 ofthe Business and Professions Cad,and my license is in PANELS / �, .x�
Z V U full,oma and eHaot. l , lw &-k�'
ti=W License _s — LIC.N IIP TO 2W AMPS """^^� �� «l
y D Commaor 201.IOW AMPS
zoo ARCI IITECTS DECLARAT N OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z'^ I understand my plans shall be used as public records.
rr SIGNS ELECTRICAL
Licensed Formation.]
S y�a'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
a�4 4V 1 hereby affirm that I am Coati from the ConhLicense Law for the
00'3 tO` following reason.(Section 7031.5,Business and Pmfa stars.Code:Any city or county TEMP.METER OR POLE MST.
lS m J which requires a permit to construct,alter,improve,demolish,or repair any smcnre
`rtY prior to its issuance,also requires the applicant(orsuch permit o file a signed statement POWER DEVICES
ly A p
that he is licensed pursuant ro the provisions of the Contractor's License Law(Chapter
d 9(commenein with Section 7"of 3ofthe Business and Professions Code SWIMMING POOL ELECTRIC
o gwi )o ) � U
or that he is exempt therefrom and the foods for the alleged exemption.Any violation of
>Y arn]03I.S by any applicant forepermit subjematM1e opplicanl to ecivil pari of OUTLETS-SWITCHES-FIX'fIJRES
no,
not more than five hundred dollars($500).
❑ I,asownerofthepmo ny,ormyemployeeswithwagesasiMirsolecompensmion, NEWRESIDENTYLELECfR _SQ.FT. STORIES TYPECONS'MUCTION
6'3� will dmhewons and e:The Contractor's
License
Law does Out
apply to an Business
and Professions Code:The C s thereon.License Law does sol apply to an owner of
ho
ownproamerty wyses,pdanr ed thatesthimpmvemennamnotihndr ioffemr thmoghhie
employees,provided LhatsuchimprovementemnorintendedmoffereJ foraele.IL OCC.GROUP NES.UNI'f5
however,the baildingor improvement is sold within one year ofcampletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
Ie).
❑ I,asownerofthepropeny,amexclusivelyconnactingwilhlicensedconuactonto QT' PLUMBING PERMIT FEE FLOODZONE APN
wnstmet the project(Sec.7044,Business and Profession Code)The Co mossum'e
License Lawdoesnotapply toanownerofacrapity whobuilds mimu pon thereon,and PERM ISSUANCE
who contractsforsuch projects with acomractons)licensed pmauant tothe Contractor's ALTER FEE SUMMARY
License Law. (EA)
❑ t an exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT#
DRAINS-FLOOR,ROOT,AREA,CONU.
WORKMAN COMPENSATIONDECLARATION SCHOOLTAX Y
❑Workers
Co affirm
onhathave aeenificam of copy the of(Seaur,0,Lab C.)which
of RECEIPT If
FlXTURES-PER TRAP
Workeri Compensation lnurance orecertified copy thereof(Sec.38W,Lab C.)which PARK FEE YN
coversall employee's harbor this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Policy ^q BUILDING DIVISION FEES
peGAS-EA.SYSTEM-O 4 HECKFEE
I [I Cenifietl copy is hereby famished. � t
❑ Certified copy is Bletl with the city inspection division. GREASEANDUSTRL ASTEI ER PT RIM GFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP s / OILSFEF ,
COMPENSATION INSURANCE
09
(This section need not beaompleted lite permit is for one hundred dollars($100) SEWER-SANITARY-STO F1L MEAN FBEI
or las )
Icertify Mat in Ne performance of We work for which Nis perrnhis issued,lahall WATER HEATER4ryENT51:CTR
not employ any Person in any manner so as to become subject in the Workers' PAID
Compensation Lmet.f Califomit. Dam WATER SYSTEM/TREATING
Z Applicant Data Receipt#
O
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FILMS. SQ,FT. TOTAL:
L—I (moi become subject to the Workers Compensation provisions of the Labor Cade,you must
LCi forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I herebyaffirm chauherc isocatamaran.lending agency for the performance of TOTAL: FLECBIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
LIa rr Lenders Name PLUMBING FEE
p U
LandersIcertify
the QTS'. MECHANICAL PERMIT FEE
LkI I certify that 1 have read this application and stare than the above information is MECHANICAL FEE
comer.lagree to comply wit all city end county0rdirmncee and some laws painting at PERMIT ISSUANCE
F^ y building construction,and hereby molso irerepresemance.11his city hooter upon the
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
�^. (We)agree to siva,Indetrmify and keep harmless the City of Cupertino against
liabillues,ii ems,cost and expenses which may in any way scene against said City AIR HANDLING UNIT(TO 10,0010 CFM)
n cc of the granting of Nis poo if.
/ai9-R3 1AIR HANDLING UNIT(OVER 10,000 CFM)
Si,4.mre of Appliwm/Connector Dee EXHAUST HOOD(W/DULT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Willrhe applic.nof future buildingoccupantatore or handle hazardous imperial HEATING UNIT(OVER 100,000 RTU) IOTA
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectio.25532(a)Y
CI Yes ❑No VENTILATION FAN(SINGLE RBSID)
ISSUANCE DATE
Willthcapplicamorfuthe building oecup mussequipmentordevices which emit
BOILER-COMP(3HP GR I W,BRo BTU)
hasardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000RTU) ® p
13 Yea 11 No NEW RESIDENTIAL MECH. SQ,Ff.
I have read the hsamaous materials requirements under Chapter 6.95 of the ®bh T /9
02-
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat
ifthe building does not currently have a tenant.that it is my respmrxddllty to notify the
Occupant of the re uireme is which must be met prior to issuance of a Certificate of CII Y ('
Occupancy.
Owner m authnrimd agent Date TOTAL: ISSUED BY:
OFFICE