25296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF XPERTINO R A PERMIT NO.
Bun.mNc DIVISION APPLICATION/PERMIT PLDMernc.MEcxANIcaL 25296.
BUILDING PROJECT IDENTIFICATION
B ING ADDRESS: - SANITARY NO. APPLICATIONSUBMHTALDATE
Ov�3
r_&7A-) tJv �.�
UNIT# LOIN
O HSNA e: S14 CONTRACTOR'S NAM LIC NO: N/C CONTROLN
ARCHI MCT/ENGINEER: LIC NO: DDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEg BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL J
JjC=zJ00 Ihereby affrmthat Iision 3 ofthnsedunder s,malvisionnimus Cprm9(commencing with
4100 full
orceand of Olvlslon3o[the Business end Professions Code,and mylicense is in PANELS
K+�1 C full force and effect.
atty Date Class Liar UP TO2W AMPS
m G y Dote Contractor 201-1000 AMPS
R O ti K ARCHITECTS DECLARATION OVER 10130 AMPS - SQ.FT.FLOOR AREA $/SQ.ET.
qqq I understand my plans shall be used as public mcold,.
rvr SIGNS ELECTRICAL
Licensed Professional B N
fiflil1
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �__,
a0.0.a� L F I hereby n,I m that 1 am exempt from the Ge cions ra l:Anne Lew for Ne `- _
41'�+Qm following to consumer.
Professions Co de:Any city structure TEMP.METER OR POLEINST. ( ) �14 i� s.�
fy�rn which requires a Permit conswc[,aline improve,demolish,or repair any etmcmre i ER
P3�� pour to its issuance,.dmmquires the applicant forsuch permit to flea signed statement POWER DEVICES t
G5 q p that he is licensed pursuant or the provisions of the Cantrectot's License Law(Chapter
o�a 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VAL TION
Wim or that he is exempt therefrom and the basis for The alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURF,S
4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR 5 .FT.
y ❑ I,asownerofthepmo ny,ormyemployeeswiNwMesastheirsolecompensation, -SQ.FT. TYPECONSTRUCr10N
y will do the work,andthe swmure is not intendedaroffered flmle(See.TufLi cairuss
and Professions Code:The Conwcw's License Law does not apply to an owner of
property"a buildsorimpowes thereon,and whodocs such workhimselforthroughhis OCC GROUP MS.UNITS
own employees,provided that such i mpmvemenrs arc not mended m offered For sale.If,
however,the building or improvement is sold wheinone yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Las the ponm(See.71) amexclusively camnming withde:) he Contnotoro
Licensecorestrat the project(Sec.loan
Business and Professions Cale)The Crown,and PERMIT ISSUANCE
License Law dcersuchsims applypjects ownerofaopeny whosestpuorintprovu thrown,and
Lho icense raw.forsaoh projeaawi@econtrecsm(s)lioensedpursuanpotha Convector's ALTER VENT.WATER(EA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason OUTSIDE EES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date RECEIPTr
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATIONDECTARATION SCHOOL TAX Y N
❑ loa Ccuyarfifmthmlhave a rance areffi ofcopythemof(ee.38or Lab C.)ate which
RECF.IPI'r
Wnrkers'Compensation Insurance oraartifed copy thereof(Sec.3g08,Lab CJ which FIXTURES-PER TRAP PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT r
Policy A BUILDING DIVISION FEES
Company
❑ Clopant' ed copy is hereby famished. GAS.EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectionncednot he completed ifrhe pewit is for are hundred dollars SHan SEWER-SANITARY-STORM EA.201 ENERGY FEE
orlexa)
I certify that in the perfowance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/ELECTR -
not employ any person in any manner so as as become subject to the Woders' PAID
Compensation Lex.f Califomia. Date ATER SY MfMEATING Date Reeciprr
O z Applicant
0 NOTICE 1.0 APPLICANT:If,after making this Cenifcate of Exemption,you should RESIDENTIAL PLME. SQ.ET. TOTAL:
55formalsubject to the Workers Compensation provisions ofthe Lobar Code.you must
LLLa^^^ > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
H
W z
CONSTRUCTION LENDING AGENCY I SEISMIC FEE
rr--Rea 1 hereby affirm That there is 9],construction lending agency for the performance of T ELECTRIC FEE
V O the work for which this .it is issued(Sec.30Civ.CJ
Lenders Name F PLUMBING FEE Lenses Address QTY. MECHANICAL PERMIT EEE
C1 1 certify ft'the drat I neve road this application and stare that the above information rmming is
correct. la reemcom 1 then cit and count ordinances wdstate laws restoring m PERMIT ISSUANCE MECHANICAL FEE
B Pd`^'i Y county 8
J 4 building construction,and hercbyauthoaze purposes.
Lives of[his city to enter upon the CONSTRUCTION TAX
L) 7 ebov We)igred Property for inspection purposes. gLTCR OR ADD TO MECII.
�r (We)agree to save,indemnify and keep mayinhoundess the Cityof
eagaCudamino against
linbilities,ju gmenn,cosy andexpenses whichmay in any way acerueegat at aeiQ Ciry AIR HANDLING UNIT('fO 10,000 CFM)
incense necofflegraatingofrhispermit �r /
/�7 AIR HANDLING UNIT(OVER I0,0(IO CFM)
ignature of Applican wn r Date EXHAUST HOOD(WIDUCT)
PAID
H RDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Data RecciprN
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TO
as defined by the Cupertino Municipal Cade,Charge,9.12,and the Health and Safety
Coda Section 25532(a)7
11 Yes 11 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DA
WilDM1en licant orfuturebuildin ruses BOILER-COMP(JHP OR 100,000 BTU)
pp goccupan quipmenmrdeviceswhichemit
hazardous air contaminants ss defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? P p
❑Yes ❑No NEW RESIDHNTIAL MECH.-SQ,FT. Y' PO
I have read the hazardous materials requirements odder Chapter understand
of the JULCalifornia Health&Safety Code,Sections 25505,t it
and 25534.I understand that tl�IB'tIIL (,`,[/�r,R•p/�J//l
if the building a re not currently have a tenant that it is my responsibility to notify the N
occ upas of the requirements which most be met prior to issuance of a Certificate of 0I Y7 I
caPancr. N i IIIYQ
Ownerorawhorizedagent Date TOTAL: ISSUED BY:
OFFIC