25184 PPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ITY OF CUPERTINO BUILDING 1 -KLECrRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 2518o1•�
A
BUILDING PROJECT IDENTIFICATION J
UII. IN ADDRESS: ra� A SANITARY NO. APPLICATIONSUBMITTALDATE
s �G/sr r Axe UNIT# LOT# 1g�+g�+y
W NAME: PHONE: CCgITR R'S NAME: LIC NO: `+'
L (!•�- �� y lC5.0 ! NIC CONTROL#
AR IW..CT/IiNGINEER: LIC NO: ADD
a4'T! �f 6.Q El
ONTACf: PHONE:
_ /, QTY. ELECTRIC PERMIT FEE BUILDING ELECT PLUMB PERMIT INFO
MECtI
QZ -0�J GLh' PERMIT ISSUANCE 14
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Q=z Iherehy affirm rhetlem licence)undaprovisions ofChuper9(mmmencingwith
D400 fallI n]andafect. mnJofthe Business and Professions Code,and mylicense is in PANELS � �
Fy full farce and affect.
y License Class Contractor
ITP-02110 AMPS
GG
Data D 2111-IIXN1AMPS
Sea_Z
ARCHITECTSx.seDECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 Iundcmwd my Alone shall4 usedm Publicreords. OVER IgIU AMPS
1=N Licensed SIGNS ELECTRICAL
Licensed Professional
O < OWNER-BUILDER fo n she CoA-ION SPECIAL CIRCUIT/MISC.
a F I hereby n.(Se that I am exempt fmm me Contractors License Lew for the
3aran which following rtasoa(Seclion]oJLS,Busineuand Professions Conde:m-nony city arcaumy TEMP.METER OR POLE INS-,
ISm.] which am issuance,also
mconsthealter,impmve,demolish,ore a sig anystructure
!!IY�
pow rois issuance.deo requires the applicant for such Aeration fileasigneJ statement POWER DEVICES
a p0 thm he is licensed p manuo m she provisions of the Contractors License Lew(Chapter
Lxo�• 9(somenting wSection ID80)of Division 3 ofthe Bminessand Prefceeka,Code) SWIMMING POOL ELECTRIC
mith 1I VALUATIn�yy�
_W❑or or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES { �� T�
EZQSection 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of {{{{
:st 0 nm nam span Dve hundm l dollen(5500). 1
m ❑ I,asownerofinepropeny,armyemployceswithwagesmtheirsolecmmpensauon. IR6VDFNT7SL�.E SQ STORIES TYPE.CONSTRUCTION
d .. will do thework,and the structure is not imeadedoroffered forsale(Sec.RHI.Business
and Professions Code:The Conrncmrs License Low does not apply to an owner of
propenywhobuildscrimpmves thermn,and whodoes such workhimselforthroughhia ( OCC GROUP RES.UNITS
own employees,providedthatsuchimpeovemb ut
enenotimm�dederoffered 6rsele.If, J
If however,the building or improvement is sold within one yearofcompl,tion,theowner-
huildcr will have the burden of proving that he did not build or improve for purpose of DATE
sed").
❑ 1.mowmroftheproWM,emexclusivelycmn ingwithlicensedconeadorno PL - EF. FLOODZONE APN
construct the rat o(Sec.]044,Easiness and Professions Code:)She Contmcturs.
License Low doesnot apply to an ownerofproperty who builds or improves thereon,and PERMIT ISSUANCE
whoconuects fmsuchprojects with a contractors)licensed pursuant to the Convectors
License Law, ALTER FA)
FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this remon 6TlTBACK 1-.OW PROTECT.DEVICE SIDE
SANITARY YN
Owner Date - - RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.AREA,COND. SCHOOLTAX YN
❑ I hereby affirm that l have scenificateofconsentat self-insum,ora certificate of FIXTURES-PER TRAP RECEIPTX
Workers Compematiun lnsuranceor a ceoifled copy thereof(Sec.3800,Lab C.)which PARK FEE Y_N
coven all employ«s under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
policy BUILDING DIVISION FEES
Cy GAS-EA.SYSTEM-OVER 4IEA) PLANCHECK FEE
Certified copy is hereby famished.
nifi,d copy is filed with the city irupation division. GREASPJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section m,d not becomplerW ifthe permit is forma,hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I con ifythat in the pefommtwo oftha work for which this permit is issued,Ishan WATER HEATER W/VENT/ELECTR
not employ any Person in any manner so as to become subject to the Workers PAID
Compensation Lawsof Califomia. Date WATER SYSTEM?REATING Date Receipt#
Q z Applicant
z NOTICE TO APPLICANT:If,after making this Corificutc of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL;
become subject to she Worker's Compensation provisions of the Labs Cade,you must
forthwith comply with such Provisions or this faed BUILDING FEE
ermis shell be drrevoked.
Lkl C4 Ft P
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby of oro that there is a construction lending agency for me performance of
V O the work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
u" P Lenders Address QTY. MECHANICAL PERMf1' FEE PLUMBING
LUST I coolly that 1 have and this application and state that the above information is MECH L FEE
correct.Iu,nom comply with all city and countyordinances andstate laws relining to PERMIT ISSUANCE
L) z building construction,andhereby atuhorize repreaemadves ofthis city toemsr upon me CO TRUCI'ION TA
abmntion
ove- eed pr.,ny for inspection purpm,e.. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep humdess the City of Cupertino against
Iiabilidea,judgment,cosbaadexpensawhichtnyinanywayacemea dntase Cily AIR HANDLING UNIT(TO BLOW CFM)
In conequ oftheg It ofthisa
AIR HANDLING UNIT(OVER 10,11110 CFM)
OsEpAne of Applinnt/Convactor .--. are EXHAUST HOOD(W/DUCI) 1
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receip
Will the applicant or for=building occupant store or handle hmmdous material BEATING UNIT(OVER IW,glO BTU)
ox defined by me Cup,rrom Municipal_Code.Chapter 9.12.and me Health and Safety
Cade.Seth 11Yes ❑No 25532(gT
❑ VENTILATION FAN(SINGLE RESID)
CE MATE
Will 1heapplicenwrfmurebuilding acupentuseequipmenmrdevices whichemit BOILER-COMP(JHP OR 1W,000 BTU)
haaardous our carmaminamb as defined by me Bey Area Air Quality Montego.., BOILER-COMP(OVER IMMB BTU) dU{V 0 07 eggs
Uistr d
13 Yes ❑No NEW RESIDENTIAL MECII. SQ,PT.
I have read the It rardoas materials requirements ander Chapter 6.95 of the CITY Ur UuptM I wU
if the uil ingdo&Safety Code,Sections 2350&255)3 and 25534, lay to mond that
ifthebuildinge on notnmswhave atenant,that it is my responsibility rnotify the
occupant of the tequircmenu which must be ma prior m iuuenu of a Certificate of
Occupancy.
s Owner or moloorircd agent Data TOTAL: ISSUED BY'OFFICE ---