25778 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
UI G-ELEC FRICAL PERMIT NO.
! CITY OF CUPERTINO PLUMBING-MECHANICAL n C�J'] Q
BUILDING DIVISION APPLICATION/PERMIT - L J I t o
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /ww e 22,,rrss SANITARY NO. APPLICATION SUBMITTAL DATE
Z2 3 V� (Art TA &AAAA � "UNIT# LOT#
OWNERS NAME: PHONE: CO RACI'OR'S NAME: LIC NO: CONTROL#
2N v�SSr 733- S •N E>E eeeor1 Nrc
RCHITECIDENGINEER: LIC NO: ADDRESS: y ��Y Lr,' ❑
/XW-/)//2
/CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
I,(1 J HC-2 U��2'/�-o6G� ' PERMIT IS NCE 15-00
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL DESCRIPTION
09y lhembyaffion that I ma licensed underprovisionsof Chapter9(cotmnencingwith.
Vn00 Section W00)of Division 3 of Ne Business and Professions Code,and my license is In PANELS , 1
! y� full force and effect. U
F� License lass C—� Lic.tl Y/ UP TO 200 AMPS
w,=y
Date 1' Contractor 201-IOOO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS
O Z'-'G I underxmnd my plans&hall be used as public records. Y
SIGNS ELECTRICAL
Su�� •] Licensed Professional I
�y OWNER-BUILDER mDECLARATION SPPCIAL CTRCUIT/MISC.
16
WW 1 hereby affirm.(Se that I am exempt from due Contractors Co License Law for the
3 k vFi following reason.(Section 7031.5,Business and Prhfeesione Code:Any city or county TEMP.METER OR POLE INST.
O4 which requires a permit to concoct,alter,improve,demolish,or repair any swcturc ® I
r^Y prior to its issuance,alan requires the applicant for such Permit file a signed statement POWER DEVICES G
�¢O that he is licensed pursuant to the provisions of the Conturim's License Law(Chapter
OrG SWIMMING POOL ELECTRIC 1
W aY. 9(commencing with Section Division the Business Slid Code) �
W^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
livi
QSection 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of
rail-me tban five handled dollar& 0).($50
O NEW RESIDENTIAL ELECfR _SQ.FT DAT TYPEC S1 RUCTION
L ❑ i.moofhewrk,anhcpropeny,otmyemtendedoroferegcsaetfered ic(sole compensation,
will JothewonsCde ateContre isnot r's Lienee Law
act appl(Seey
7044.Business
and Professions Code:The Contractor's License Lvw does not apply lf an owner of
property who builds orimprovesthereon,endwhodoessuch workhimeelfortlaough M1f, OCC. UNITS
employees,providedthntsuchimprovemenm are nmimendedorofferedforsale. OCGROUP
If,
however,the building or improvement is sold within one yearofcompletion,me owner- TOTAL:'30.00
builder will have the burden of proving that be did not build or improve for purpose of
sale.). .
s❑ I,as hwmd
neroftheproperty,aexusively, contracting with licewd
nsedntrnorsm QTYPLUMBING PERMIT FEE FLOOD ZONE APN
commsct the project(Sec.71144,Business and Proleasion&Cade:)The Comracmr's
License Lawdoes not applyto an ownerofpropeny whobuildsorimprovesthereon,and PERMIT ISSUANCE
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FE S
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,ARBA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
(hereby affirm that l have. of consenuoself-insure,ora certifrcamof FIXTURES-PER TRAP RECEIPT#
Workers'Compensation lnsuranceor a cenifiedcopy thereof(Sec.3800,Lab C.)which PARK PEE Y N
coversall ampJJR�y esypg¢�tha u. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# �S�LCYY� �yNa BUILDING DIVISION FEES
ComW^Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑/Czttified copy Is hereby blo idled.
Certified copy is filed with the city inspection division. GREASPNNDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dollars 5100) SEWER-SANITARY-STORM EA.2001'L ENERGY FEE
or less)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation Lawsof Califomia. Date WATER SYMNIT'REATING Date Receipt#
0 z Applicant
z 0 NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L4 become abject to the Workers Compensation provisions of the Labor Code,you meal -
! , forthwith comply with such provisions or this Arrau shall be,deemed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
zI hereby affirm that there is a construction lending agency for the performenem of
O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
t—� Lenders Name
C) E^ Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V I certify Nat I have read this application and site that the above information is MECHANICAL,ME
>4 a correct.I agree to comply with all city and county ofdirmnces and state laws relating in PERMIT ISSUANCE
U z huildingconsuictioa, it hereby. ofthiscity to enteropon the - CONSTRUCTION TAX
above-menf ned pa
r ins&tion purposes. ALTER OR ADD TO MECH.
�-• (We) ree toem tfy and keep harmless the City of Cupertino against
liebil'ies,j emd penes whichnmy in my way swerueagainatsaid City AIR HANDLING UNIT(TO 10.000 CFM)
ue oFtg this pemtit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sign mu 'h pelicantre[or pate - EXHAUST HOOD(W/DUCq PAID
HA BOGUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt It
Will the applicant or future building occupant sire or handle hazardous material HEATING UNIT(OVER 100,0100 BTU) TOTAL:
as defined by the Cupettino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
El Yes ❑Na VENTILATION FAN(SINGER RPSID)
Will theapplicnntorfuwre buildingwcupen[oseequipmenmrdeviceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous sit examinants as defined by the Bay Arae Air Quality Management BOILER-COMP(OVER 100,000 BTU) Q k�
islricll V
❑Yes 13 No NEW RESIDENTIAL MECH.—SQ.IT. nL�I U
1 have read the hazardous materials requirements under Chapter 6.95 of the AVO" 24 1993
California Health&Safety Care,Sections 25505,25533 and 25534.I understand dust
if the building does not currently have a tenant,that it is my responsibility to notify the I/Y
occupant of the requirements which must be met prior to issuance of a Certificate of V CUf l.Ur-C
Occupancy.
Owner or amho ism agent Date TOTAL: ISSUED BY:
OFFICE