25904 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -ELICI MICALPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25904
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPWCATONSUBMHTALDATE
T \ 1 g �Nivs JCTsLOT
lyR_
OWNER Co PHONE
OACTORS
Rcs/\o N � comTJ LIC NO: NIC CONTtOL
#
ARCHITE
LIC NO:
(505'10 FIFcu10ufl Cr-, s ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMI]ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
K,wE M=Z I hereby affirmthat l am licensed underprovisionsol'Chapter)mommencing with
Ffiillcfoceand ffecrvision3of the Cosiness and Professions Code,and my license is in PANELS
UPT02MAMPS
On6 L Dote Co^tmelor 201-ION AMPS
Fy Z_ ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA 5/SQ.IT.
OZ-❑ I understand my plans shall be used as public records. OVER 1IXp AMPS
Ftn5w SIGNS ELECTRICAL
6'"' „,j Licensed Professional
E5'� 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
P10aU 1 hereby affirm that 1 am exempt fmm the Conlmemr9 License Law for the
t33 0.F following reason.(Seaton 7031.5,Business and Professions Code:Any city or wanly TEMP.METER OR POLE INST.
�O which reyuircs a permit to ccnteruct.itim,improve.demolish,or repair any structure
t�}2 priorto its issuance,also requires the applicant for such permii tottfile u signed statement POWER DEVICES
pj COo that he is licensed pursuant the provisions ofthe Contractors License Law(Chap¢r SWIMMING POOL ELCCfRIC
4 e 9(commencing with Section 70)(Hof Division J ofthe Businessund Professions Code) VALUATION
yYj�y omhathe isescmpvherefromand mebasia fortheallegedexemption.Any violusionof OUTLETS-SWITCHES-FlKTBRESS
Y Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
not mom than f.e hondral dollars($500).
❑ I,usownemFlhe progeny,ormyemployeeswithwagesestheirsolecrmpcmation, NEWRFSIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
n.V2 will do the work,and the structure isnot immndedoroffered(orate(Sm.7044.Business
and Professions Code:The Contractor's License Law does not apply to an owner of Its
propnty whabuildsmimpmves Hereon,ondwhodocasuch workhimselforthrough his
ownemployces,pmvidedthaisucliimpmvementswenmintendedoroffeWfareola.If, C.GROUP RES.UNITS
however,the building or improvement is sold within ane yearofcampletion,theowner-
builder will have the burden 6f,moving that he did not build or improve for a f "I"
. provi g prov purpose
ala
le.).
❑ I,as awnerofthe property,em exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sea 7044,Business and Professions coda:)The Contractors
License Lawdoes not apply to an ownerofproperty whobuilds orimprovesthereon,and PERMIT ISSUANCE
who contracts forsuch projectswith aconuactor(s)littnxd pursuant mthe Contactors
License Law. ALTER-DRAIN&VLNT-WATER(EA) FEE SUMMARY
❑ I i m exempt under Sec. ,B&PC for this reason OUTBACK FLOW PROTECT.DEVICE SI FE
SANITARY Y—N
—
Owner Dam DRAINS-FLOORROOFAREA. REC "it
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have a cetiftcatn ofcovsert to self-insure.or am iftcam.f, FT%TUBES-PER TRAP RECEIPT#
Workers'Compensetion lrmumnce oraartifedcopy thereof(Sec.Jg00.LebCJ which PARK FEE YN
covers all employee's under this pemtil. OAS-EA.SYSTEM-1 INCA OUTLETS RECEIPT X
Policy p BUILDING DIVISION FEES
Company GAS-BA.SYSTEM-OVER 4(EA) PLANCHECK PEP.
enified copy is hereby famished.
Certified copy is filed with than city inspection division. GRPASEONDUS]RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars($10B SEWER-SANITARY-STORM EA,201)(1117. ENERGY FEE
or less.)
I certify that in the perfomance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner ao Is le became subject to On,Worker( PAID
Compensation Laws of California Data WATER SYSTEMUREATING Da¢ Receipt#
,z Applicant
z C' NOTICE TO APPLICANT:IL after making this Cerd Scam of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
V) become subject o the Worker's Compensation provisions of the labor Code,you must
F f'" forthwith comply with such Provisions Or this permit shall be deemed revoked. BUILDING FEE
a [] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.309],Civ.CJ
Lenders Name
U" Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I3J certify that 1 have Teed this application and state that the above information is M
oriECHANICAL FEE —210
�" Cy Co.,.orlagree to comply with all city and,manyordirmnwsand smte lowarelating m PERMIT ISSUANCE.
building construction,and hereby authze mpma metivesofthis chymemeruprnthe CONSTRUCTIONTAX
rJ z shove-memio^ed pmpeny for inspection purposes. ALTER OR ADD TO MECIL
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liubilities,judgments,costs lad,.N hich ay in any way secrueafificamid City AIR HANDLING UNIT(TO 10,000 CFM)
imcz umre of�e/kbaBa a srwmit. a— /0-5y
(\0 �1/A�` //1 AIR HANDLING UNIT(OVER 10,00)CFM)
mtmof AAli ant/Comrmmr Dam E%HAUST HOOD(W/DUC) PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,003 BTU) Data Receipt#
Wil l the applicant or future building occupant store or handle haurdous materiel HEATING UNIT(OVER 100, BTU) TOTAL:
as defined by the C^penum Municipal Cede,Chafer 9.12,and the Health and Safety 003
Crile,Section 25532(1)? VENTILATION FAN(SINGLE RMID)
ID Yes ED N^
ISSUANCE DATE
Will dmapplicam or futurebuildingoccupantumequipmenlordevices whichemit BOILER-COMP JHP OR IOg000 BTU)
huuodous air cmdondir eats as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IN,"BTU)
Disma?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. pp
I have rend the hazardous materials requirements under Chapter 6.95 of the /^ ry ' D
ifthe uil ing re&of cur Cody,Sections 25505.25533 and responsibility
I undenoM that
if the building deer not meats w have a tone,,that it is my responsibility a notify the
occupant of the regoiremems which mot od met prior to issuance of a Cenifcam of Q tea\
Occapnncy.
Owner nr umhorizedogem Dam T ISSUED BY:"
OFFICE