25772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING TE
ADDRESS: /J ` 25772
SANITARY U. APPLICATIONSUBMITTALDA
22 `/� 1,,N STif UNIT# LOTH
PHONE: CQk4TRACTORS NAME: N LIC N-O:OSCT Tr.
N� CONTROL
RCHIIECT/FNGINEER: UC NO: ADDRESS: ❑
W
• CONTACT: . PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLO��StttB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑wz I hereby affirm that lam licensed under provisiomol'Chapmr9(commencing with JOB DESCRIPTION
V100 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
<IjE full force and effec.
F W License Class Lic.p �V0�o I � UP TO 200 AMPS
y y Date Conn.., 201-1000 AMPS
z8y4 ARCHITECTS DECLARATION OVER IOOOAMP, SQ.FT.FLOOR AREA E/SQ.PT.
O z'_Q I understand my plains shall be used as public records.
r4 C SIGNS ELECTRICAL
Ta LsenseJ Professional
OWNF.R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
011 I hereby affirm that 1 am exempt from rhe Cmntractors License Law for the
3 wa followingreason.(Section 7031.5,Business and Professions Code:Any cityorcounty TEMP.METER OR POLE INST.
y ,which requires a permit m construct,alter,improve,demolish,or repair any structure
O,�.E prior ro its issuance,alsorequires the applicant permit m file a signed statement POWER DEVICES
0.0 pm that he is licensed pursuant to the Provisions of the Contmemrs Lleeme Law(Chapter
pe�LL 9(conunencing with Section 700,'1)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
µIV LUATION
MO, or that he is exempt and the basis for the alleged exemption.Any violation of - u h
>' Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of OUTLETS-SWITCHES-FIXTUR -
not more than five hundred dollars($500).
❑ Leswnerofthe property,many employees with wages as theirsole compensation, NEW RESIDENTIAL ELE ass
Pe" —yI/vs'V S IE$ TYPE CONSTRUCTION
0. 4 will do th<work,and the structure isnot intended oroffered foreale(Sec.70,PLIhsinees
and Professions Code:The Contractor's License Law does not apply to an owner of
Properly who bui Ids or i mproves thereon,end who does such work hi msel f or through his
Own employees,providedthmsuchimpmvements menotimended muttered forsale.If, OCC GROUP RFS.UNITS
however,the huhiltag or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,asownerofth"property,am exclusivelycontraming with licensed contrac[Orsro QTY' PLUMBINGPERMIT FEE FLOODZONE "N
construct the project(Sec.7(a44,Business end Professions Code)The Cmunw,nrs
License Law does notapply to anowmaofpropeny whobuildsorimproves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contracror(s)licensed pursuant to the Contractor's
License Law. - ALTER-DRAIN&VENT-WATER TA) PEE SUMMARY
❑ tam exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE O TOE FEES
Owner Dam SANITARY Y N
DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT M
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
• ❑ theComy firmioninshave aceraceniieate consentmof(Snsum.".1,ab CBeare Of FIXTURES-PER TRAP RECEIPT is
Workers'Compensationder thisermieenifledcapy thereof(Sec 3800.LabCJ which - PARK FEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-1 INC.4 OUTLETS o mRECEIPT p
Ctl
Company BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER4(EA)ElCeniEed copy is hereby furnished. ( PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXLMPIION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectionneed notbecompleted ifthe permit is for one hundred dollars($101)) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the Performance ofthe work lorwhich this permit is issued,l shall WA • TER W/VENT/ELECIR
Out employ nay person in any manner so as ro lecome subject m the Workers PAID
Z Cmmpensmlou Lewsof Califomia. Date T
ERV M/IREATING Ditto Receipt if
Q Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you shouldENTIAL PLMB. SQ,FT. TOTAL:
Vl become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be dcemed revoked.
� � BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE -
1 hereby aftlrm that thea is a construction lending agency for the performance of
U the work for which this permit is issued(Sec 3097,Civ.C.) ELECTRIC FEE
w Lender's Name
O Lenders Address MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have read this application and stem that the above information is
correct Iagree to comply with all city and county ordinances and state laws testing toSUANCE MECHANICAL FEE
(� building construction,and hereby authorize representatives of this city to enter upon the _
U Z above-mentioned property for inspection purposes. ADD TO MECH. CONSTRUCTION TAX
(We)agree 1.save,indemnify and keep hales he City of Cupertino against - -
lishilitieajudgmente,caste andexpenses which may ineny way accrue ageinet said CityLING UN1,(To Ig000 CFM)
in consequence of the grunting of this permit.
1LING UNIT(OVER Io,000 CFM)
Signeturo ppllcanUCon Gor �leHOOD(W/DUCTJPAID
HAZARDOUS MATfOccuL9DtoCLOSURE
IT(T01011,0p0 BTU) Data Receip[k
Will the applicant Or(mombuilding occupantstore or handle haealtha martial
as defined io the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety IT(OVER 100,000 BTU) T
Cade,Section 25532(n)?
❑Yes 11 No PAN(SINGLE RESIO)P 3HP ORI Bigh BTU DATE
Will theapplicamorfumrebuildingoecupant use equipmentordeviceswhich emit ( )Adak hazardousair contani ent as defined by the Bay Area Air Quality Management P(OVER UM t00 BTU)Distrim? y❑Yes ❑N" TIAL MECH. SQ.PT. I5f01/ 1 7 1993
1 have reed the commandsmamdms requirements under Chapter 6.95 of the
CaliforniaHealthgSk Safmy Code,Sections le,met 25533add 25534.I understand that CITY Uh UUYenIu
if the building does not currently have a tenant,that it is my responsibility to notify the -
occup an of the regoircmenrs which must be met poor issuance of a Certificate of
Occupancy.
Owner or amhoreed agent Date
TOTAL: ISSUED BY:
OFFICE