25582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOI- -ELEC R L PERMIT NO,
APPLICATIONIPERMIT PLUMBING-MECHANICAL,
'
BUILDING DIVISION BUILDING PROJECT IDF.N'TIFICATIUN G 2 5 5 8 2
J J OQ G
BUILDING ADDRESS, �/ - SANITARY NO. APPPPLICATIONSUBMITTALDATE
1,kl ��/ G l • �- 1`�+w� INITT LOT
OWPLAqt? / F� CO RACTOR'$N LIC NO: N/C ` C_ONTN`OLM`
• ARCHITEC/IEsGINEER: `�IbYV iVa• LIC NO: ADDRESS: El
CONTACT. PHONE: BUILDING P13RMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El 11 ❑ A
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
PCZ I hereby affirm that l am licensed unduprovisions ofChapter!)(commencing with JOB DESCRIPTION
P400 Section 7001B.Miision 3o17the Business and Professions Cade,and no,been.is in PANELSfull force and effect.
�Z License Class Liag UP T0200 AMPS
L,<a Dam Co.,..r 201-1000 AMPS
F y Z ARCHITECT'S ITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
ZO y— I understood m 1 hall Earned u public ucords. OVER 1000 AMPS
OZ0 YPa^sx
Ey�j
s.W SIGNS ELECTRICAL
y�'d2y'< Licensed Professional -
�TLWU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oy 1 hereby affirm that I un exempt from the Contractors License Law for the
3 LLO`F° following reason.(Section 7031.5,Business and Professions Cade:Anyciryarcounty TEMP.METER OR POLE INST.
MpJ sn which mpriman permit m construct eller,improve.demolish,or repair any structure POWER DEVICES
Y�
pd., its issuance,9.requires the applicant fmsuch pemdt m file.signed statement
0m dto.he is licensed pursuant to the provisions of the Connectors License Law(Chapter SWIMMING POOL ELECIRI
4 04 9(commencing with Section 7")of Division Sof the Business and Prafessiom Code) T � � � WAT10N
pa^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLL'TS-SWITCHES-PI TU
F-Z Q Section 7031.5 by my applicant for a permit subjects the applicam m a civil penalty m I _ _
� p not inure than rive hundred dollars($50% NIS
SQ:FT.' y r' '
❑ I,mownttoftheproperty,ormyemployeeswith wagesmtheirsole compensation, �\ I� 'J II LfT TYPE CONSTRUCTION
y3. willdothe work.andtheaWcmrtis nmt inlended.ofPortdforsl<(S..]1146,Business ,; 0 Lt
and Professions Code:The CoMacmrs License Law does net apply to an owner of
propanywhabuadsorimproves thenvn,and whoAoes suchwoh himsalforthrough hisDATE ROUP RES.UNITS
n employees,provide.)that such imprnvemcros are not inrendeJ nr offered for oats.If,
however,the buildingorimprovemem is sold within one yearofcampletion,theca,er- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
seta).
❑ 1,asownerofthe property,unexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the pmject(Sec.7060,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law does not apply toan owner of property w ho bu ilds.improves thereon,and
whocommais forsuch projects with acenvacmr(s)licensed pursuant todu Comrecmre ALTER VENT WATER-
License Law. ER DRAIN (' ) FEESUMMARY
OUTSIDE FEES
❑ 1 an exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE.
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEITT#
WORKMANCOMPENSATIONDECLARATION SCHOOL TAX Y N
❑ Iherehy.Trion Nntlhavm cenificaa ofcanum mulf-imam,orettnifram of FIXTURES-PER TRAP RECEIP #
Workers'Compensation lnsunnce ora certified copy thereof(See.3800,Lab C.)which PARKFEE Y N
covers all employ.'.under Otis permit GAS-EA.SYSTEM.I INC.6 OUTLETS RECEIPT N
Policy It BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 6(RAJ PLANCHECK FEE
❑ Cenifedcopyisherebyfamished.
❑ Certified copy is filed with the city inspection division. GREASRINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
(Thissectier read not be compldad ifthe Permit is fofonehmored dollars($100) SEWER-SANITARY-STORM EA.200FL ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER WIVFN/ELECTR
not employ any person in any manna sou to became subject to the Workers' PAID
z Compensation Lowsaf C.lifomia. Dora WATER SYSTEMRREATING Date Roselle#
Applicant
� O NOTICE TO APPLICANT:If,after making this Ceraficam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject in the Worker's Compensation provisions of the Labor Code,you must
EFF"' ;> forthwith comply with such provision or this permit shall M deemed invoked. BUILDING FEE
4SI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the wink for which this pcmdt is issued(S..3097,Civ.C.)
Lenders Name
u" Fes" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
IVLI 1 certify that I have read this application and sure that the above irf rtmation is MECHANICAL FEE
correct.l agree to comply with Al city and county ordinances and su¢Ia.elating to PERMIT ISSUANCE
building concoction,and M1ereby authorive upresentmivesofthisciry incineration the - CONSTRUCTION TAX
U Z above-noniamed pmparty for inspection purposes. ALTER OR ADDTO MECH.
(We)ague to save,indemnify and keep hamdeas the City of Cupertino against
liabilities,judgments,costs and expenses which may in jiny way accrue aa10tyAIR HANDLING UNIT(TO 10,001)CFM)g BuisAIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applic monitor EXHAUST HOOD(WIDUC) PAID
A7ARDOUS MATERIALS DISCLOSUREHEATING UNIT(TO 100,00)BTU) Date Receipt g
Will the applicant nr fmurc building swcupnnt score or handle hazardHEATING UNIT(OVER 100,100 BTU) TOTAL:m defined by rhe Cupertino Municipal Code.Chapter 9.12,and the HealCoda Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑NoISSUANCE DATE
Will theapplicamorfuurebuildingwcupant useequipmentordevorBOILER-COMP(3HP OR 100,000 BTU)
huandous air contaminants m defined by the Bay Arca Air Quality BOILER-COMP(OVER 100,00(i BTU)
Disvict?
11 Yes 0N NEW RESIDENTIAL MECH. SQ.FT. PAID A/9DD
I have read the hasNom mnteriels"tune emu under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 0530. lumbouridthat SEP 2
if the building does not currently have a mnamt that it is my responsibility to notify the 4 19
occupant of the mquirements which must be,met prior to issuance of v Candllcate of �s
Occupancy. C1ly U
Owner or vuthariud egem Dale T ISSUED BY:
OFFICE