25872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO11. 1 -ELEC I RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL f� C O�J /�
BUILDING PROJECT'IDEN'T'IFICATION L J o I G
BUILDING ADDRESS' �- SANITARY NO. APPIJCATTONSUBMITTALDATE
OIL eDNITN LOT#
OW NAME: # PHONE I CONTRACT91I'S NAME: LIC NO:Caws? NIC CONTROL#
!fbrimer[
ARCIRTECT/ENG ER: a LIC NO: ADD
I ✓�.
U, a Nt
CON'1'aCf: PHONE: BUILDING PERMIT INFO
QTY. ELECT IC PERMIT FEE
. D ELECT PLUMB MECH
PERMIT ISSUANCE E] C-1 ElLICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
pKZ Thereby offirm that land licensed underprovisionxof Chapter9(cnmmerteing with TOB DESCRIPTION
RidE Section
force�)effeetvision3nf the Businntli q'Professions Code,end my license is in PANELS ����
(a,ZW License Clercs Lit.# �� 3Z UPT0200AMP5
oe=y Date Comrecmr f/ - 201.1000 AMPS S Ff.FLOOR AREA 5/SQ.F1'.
ZONZ ARCHITECTS DECLARATION OVER 1000 AMPS Q
OZ—tu0� I understand my plos shall be used as public records.
q="Lj Licensed professional SIGNS ELECTRICAL
JEy�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
fy�OyU I hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 U.in following mason.(Section 7031.5,Business and Professions Code:My city or county TEMP.METER OR POLE INST.
F- Oy 5 which requires a permit in conswct.Wier,improve,demolish,or repair any structure
z � 7 priormits issuance,elw requires the appiieent forauch pemtiOo Blcacigned atntemrnt POWER DEVICES
ty'<0o that he is licensed pursuant m the provisions of the Convectors Liana Law(ChapterSWIMMING fVOL ELECTRIC yA
p.Sxp0LL 9(commencing with Section 7")of Division 3 ofthe Business and Professions Cade)
o, or Nat he is exempt therefrom and the basis for the alleged exemption.My violation of OUTLETS-SWITCHES-FIXTURES
FZa Sectio 7031.5 by any applicant for a permit subject/the aMlicanno a civil penalty of
nmmom than five hundred dollars($501 NEW RESIDENTIAL F.LECTR S
[I Lmownerofthepmo ay,ormyemploymswithwagnutheirwleco Natation, Q.FT. STORIES TYPE CONSTRUCTION
n. will,the work,andthesmactum is not imendedoroffeted for sale(Sec.7094.Business
and Professions Code:The Contractors License Law does not apply to an owner of
property whobuildsorimproves thereomand whodoes such wmkhinmWforthrough his OCC.GROUP RES.UNITS
own employees,provided that such improvements are not intended or offered for sale.if,
however,the building orimprovement is sold within one years fcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,as owneroRhepropeny.amexdusivelycontncting withlicenud conwcmrno QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7016,Business and Professions Code:)The Comsacto's PERMIT ISSUANCE
License Low does not apply to an owner ofpmpmy who builds or improves thereon,and
whocontncts forsuch projects with acononcmdej licensed pursuant to the Conuactora
License Law. ALTER-DRAIN @VENT WATER(FA) FEE SUMMARY
❑ 1 mer eacmpt under Sec. ,B @ P C for this mason .I
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION ofco DECLARATION SCHOOL TAX Y N
❑ er,'Coyaffism@ailhave a uranceor ifeam of consemencof(to ce.38or aid,C.)ateof FIXTURES-PER TRAP RECEIPfp
Wnrkeri Compensation Insurance orecertifieA copy thereof(Sa.3800,Lab Qj which PARK F 1 YN_
rsall employee's under this permit GAS PA.SYSTEM I INr44 O YDIVISIOp
Polcyp l' I! i� BUILDING UI VISION FEES
Company GASEA.SYSTCMOVER4( )
❑ Certified copy is hereby famished. 1
0 Certified copy is filed with the city inspection division. GREikSW/ DUSTRL WASH I RC&�jl D GFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP L FE
COMPENSATION INSURANCE
(TTisuctionneednmbecomplemdifthepermitisfmonehundmddollars(SIWI SEWER ME
-SANITARY-ST A.2 ENERGYFEE
or less.)
I certify that in the Performance ofthe work for which this permit is issued.)shall WATER HEATER W/VENT/ELECTR
nn ploy any person in an manner. become subject to the Workers' PAID
C smtinn La fCali ie. Dote WATER SYSTEhdrrREATING Dale Receipt#
O z Applic r a
z O NO'TIC TO APP (CANT: Lafter making on eMeate ifExemption,yon should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
E-I bccomcsubjat 1.flue Workers Compensation provisions ofthe Labor Code,you most
Lei 7 forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE I
U O I hereby em thauhcm is a communion lending agency for the performance of TOTAL: ELECTRIC FEE
Nc work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name
rr Lender.Address QTY. MECHANICAL PERMIT FEE. PLUMBING FEE
U 1 certify that 1 have read this application and state that the above information is MECHANICAL FEE
>. L2.1 cmmcL I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
t I, building construction,andhcreby radiative representatives ofthis city mercer upon the CONSTRUCTIONTAX
U7 ahove-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
F7 (We)agate m save,indemnify and keep harmina the City of Cupertino against
liuhilitics,judgment,cos ander ich may in any wayaccrue against snit City AIR HANDLING UNIT(TO I0.0(*CFM)
in consequnce oft gr ting thise it l
/ /� AIR HANDLING UNIT(OVER IO,g10 CFM)
ewre ,hcafiUComrw,.r / Date EXHAUST HOOD(WIDULT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM.Mp BTU) Date Receipt#
Will thcapplicam or future building accupamatore or handle haeudous material HEATING UNIT(OVER IOO,gXS RTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(87
❑Yes 13 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Willtheapplicanwrfumr,buildingmcupanmseequipmenmrdevices which emit BOILER.COMP QHP OR 1110.(X10 BTU)
hazardous air cmnamiount,es defined by the Buy Area Air Quality Management
.Districl? BOILER-COMP(OVER IIXI,(Wq BTU)
^ p
El Yea ❑No NEW RESIDENTIAL MECH.—SQ.FT. P a'7 B
1 have read the hazardous meteools requirements under Chapter 6.95 of the
California Health @ Safety Code,Sections M505,25533 and 25534.I understand Nat JAA1
Qg
ifthe building does not currently have a tenant that it is my msponsibiliry to notify the 'v Vero
acupwt of the raluimmenu which must be met poor to issuance of a Cerifinte of rV
Occupancy.
Owncrnrauthidiodagent Date TOTAL: ISSUED BY: I' IIII
OFFICE