25392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO. UILIHNU.ELECTRICAL PERMff NO.
APPLICATION/PERMIT PLUMBING'w MECHANICAL 25392
BUILDING DIVISION /s BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOTp L 1�
OWNyIt s iP99-E `� CONTRA R'S NAME: _ LIC-NO:
5 ,'J7L IT[ JLJ 9 hlC CONTROL#
RCHITECI'/ENGINEER: LIC NO:
ONTACT: PHONE: E '4lDp 51dnK ❑
BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PIT MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
y.Z I hereby affirm tat an licensed underpowlsionsof Chnpmr9(commencingwith
00 Section 7000)of Division 3 ofte Businessand Profn.mrC a and my license is in PANELS
full
ftar
Wwb6brpd n<ZW License Lica r
UPT02MAMPS
Dole
Cantmcmr' 201-I"AMPS p
z O y.4 ARCHITECTS DECLARATION OVER 1000 AMPS .PL OR AREA $/SQ.PT.
1 understand my plans shall be used in public records.
I
ySIGNS ELECTRICALp'1yLicensedProfessioal 'sJ cy,i ,M1�d\pg < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O0.0 I hereby affirm chat 1 sm exempt from the Commences License Law fm to
3 O or following reason.(Section 7031.5,Business and Professions Code:Any city orcranny TEMP.METER OR POLE INST. ATE
y 5 which requires a permit to consumer,alter,improve,demolish.or repair any structure -
F }� rt
p000 its issuance,also requires Ne applicant for such Permit to file a signed statement POWER DEVICES -
aC OC that he is licensed pursunm to the provisions of the Cnmrecmr's License Law(Cheerer
deLL 9lcommenclag with Section 700(p of Division 3 ofte Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
'y,may
or that he in exempt therefrom and the basis for alleged exemption.Any violmionof OUTLETS SWITCHES-FIXTURES
[�h�zQ Section 7031.5 by any applicant for a permit subjects the applicant a a civil pevlty of v ('y
not mon that fivehundred dollars($5002 NEW RFSIDENUALELECfR _SQ.PT. STORIES TYPECONSTRUCDON
❑ Lmowneroftepropeny,nrmot imerubvi re thwegaesalel(Sec.7 m,Business
will dotheand thestructureContractors
License reoffered!for at apply
a owner
of
proand enyPonwho
ldsoCodri The Convenors License Law don not apply lf rt owner is
owneo,wbabuildsviimprovesth whodoes;such dormintncen Nmselfmthaughhis OCC.GROUP RFS.UNITS
employees,provided t lit such improvements are nor i mended or offend for sok.If,
however theavete burimprovementissolde did not yam or improve forn.to puowner TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
ElI.mownerofthepmpHy,amexclusivelycmuntingwitlicensedconvncana QTY. PLUMBING PERMIT FEE MOOD ZONE "N
construct the project(Sec.70a4,Business uad Profession Code:)The Contractors 15'.
Liccnm Luwdaesnot apply toennwncrofpropcny who builds nrimproves tartan,and PFRMIT'ISSUANCI?
whocontracta forsuch pmjecta with a contortions)licensed pursmin othe Comtrecncea
Licease Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this Leeson SI .F
BACK FLOW PROTECT.DEVICE. SANITARY YN
Owner Date RECEIPT#
WORKMAN COMP ENSATIONDECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOLTAX Y N
xm hereby uffrm that consent have a certificate of conseno sei6m
insu ,or a certificate of FIXTURES.PER TRAP RECEI"#
kers'Compensution Tnumnce or a certified copy tereof(See.3800,Lub C.)which PARK FEE Y N
mvemallerpRWp nupgel is permit GAS-RA.SYSTEM.11NC.4 OUTLETS RECEIPTp
Policy# //�/YY Y ) BUILDING DIVISION FEES
Company' ' GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ feniried copy is hereby famished.
Certified cap,is filed with the city inspection division. GREASE4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTNCATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not Po completed ifte permit is notion,hundreddollw(SIW) SEWER-SANITARY-STORM EA.2WT. ENERGY FEE
or less.)
I cenify that in the performance of the work for sehichthis permit is issued,I shall WATER HEATER W[VENT/ELECR
not employ any person In any manner so as to been.subject to the Wmlocrs PAID
Compensation Lawsnf Culifomia. Dare WATER SYSTEM/TREATING Dam Receipt#
p z Applicant
z 0 NOTICE TO APPLICANT-,If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
r ti become subject to the Workers Compensation provision Labor Coda.the LCoda.you must
had with comply sent such provisions or this Permit shall be demerit revoked. BUILDING FEE
w z CONSTRUCTION LENDING AGENCY SEISMIC FEE
CJ 1 herehy affirm]but here is a consmmion lending agency for to performance of
U O the work for which this Permit is issued(Sec.3097.Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name 1
LT. F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE 2)•U
U I cenify at I have read this application and state that the above information is
correct le reeamm I tall cit dcoum Ninwces and stnm laws relnrin m PFAMITISSUANCE MECHANICAL FEF,
8 PYwi Yen yo g
_ buildingcanuactlon,and hereby autmim representatives ofthis city to enter upon to CONSTRUCTION TAX
V Z above-mentioned papery for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and keep harmleea to City of Cupenino against
Imbilitien,judgmrms.costs and expenses wh'h may in my way acerae against said City AIR II ANGLING UNIT(TO IQ0(0 CPM)
in c enc f the grenting
L �777//j AIR HANDLING UNIT(OVER 10,000 CFM)
SigraborcrApplierinincritracur, Dem EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,0(70 BTU) Dam Receipt a �I
Will the upplicom or future building occupant sate or handle havallons material HEATING UNIT(OVER 1701,000 BTU) TOTAL:�HJ
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Heap and Safety
Cade,Section 255324)?
❑Yes 11 No VENTILATION PAN(SINGLE RFSID)
ISSUANCE DATE
Willthea licani oTfulumbuildin antuxeui entardeviceawhichemit BOILER-COMP SSP OR 10(1,000 BTU)
PP goccuP 9 Prn
.,.Nous air conm:,unts as defacd by the Bay Area Air Quality Management BOILER-COW(OVER IUQ000 BTU)
Dkid"?
❑Yes 13 No NEW RESIDENTIAL MECH. SQ.FT. PAID
1 have read to haeardom materials requirements under Chapter 6.95 of to
California Health&Safety Code,Sections 25505,25533 it is and 25534. 1 understand tat NOV 2 2 19
if to huilJing cats not cutre, have a mnam,that a is mreso notify the -
nf the r u rents h �11y,,�su=e. cete oftkcuO eroraumm ti f amt - TOTAL: ISSUED BY: - ` VI I ITV
OFFI