25749 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
isfin,DTTN-kILE,LTR PERMIT NO.
CITY OF CUPESIO NO APPLICATION/PERMIT PLUMB,G-MECHANICAL n C (J
BUILDING DIVISION BUILDING PROJECT IDENTINICATIUN LJ J
BUII.1 GAE14WS, rL/I SANITARY NO. APPLICATION SUBMfPI'AL DATP
LOT D U 1 p
O CO COM R'. NAME N/C CON'IROLp
R I'IiCLENGIb iER: LIC NO: ADDIRESY. ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MELEE
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ihereby affirm that l am licensed underprovisions of CTapter9(commencing with
L'100 Seb...nB(nU ar Divieinn3of the Business and Professions Code,and my license is in PANELS
C fel -s u mrd effect.
<P xClnss Lic.p UP T02g1AMPS
o""6, Date Contractor 201-1000 AMPS
7i_=L ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0z C 1 understand my plans sM1all h used as public records.
Fr? W SIGNS ELECTRICAL
6� Licensed Profnalood
C CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOdU I hereby affirm that I an exempt from the Commons License Law for the
W,E000s following meson.(Section 0031.5,Business and Professions Code:Any city oremnty TEMP.METER OR POLE INST.
F'aONj which reyuiresaperals memnstheapmgimprovuchper permit
or repaired viaumen t
��YS prior its issuance,also requires the applicant for such pcnnit mflcnsigned smmmenl POWER DEVICES ,
,W<0 that he is licensed pursuant to the provisions of the Connector's License Law(Chapter
aKau 9(commencing with See iot7")of Division 3ofthe Business and Professions Cede) SWIMMING POOL ELECTRIC ( � I�/ L ON
W_, or he is exempt therefrom and the basis for the alleged excmpdon.Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
not mom than five hundred dollars($50[n
�p ❑ I,usnwncrmfthc I yem0 Yeeswm gnus pensadon, NEW RESIDENTIALELEM .Ff. DATE
proper y,onto to lh wu Iheirsolecom S ) IES TY�ECONSTRUCTION
y'3� will do the work,and'he onature is net immrdednmfrered hostle(Sce.]094,Business _ J
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsor improves therco,in l whoduessuch work hame,ifurthmugh his
cmpinyccs.provided that such impmvememsamnotimendedoroffcred fnrsale.If, OCC.GROUP RES.UNITS
M1owcvcn,the building on Improvement is,old within one year of mmpheion,the owacr- TOTAL:
builder will have the burden of proving that he did not build r improve for pmpow of
sale.).
❑ I,as owrrofche property,amexdusivelyconvacringwithliansed cantnemrsm QTY. PLUMBING PERMIT FEE FLOODZONE APN
consto ct the project(Sec.7044,Business and Professions Code:)The Comment's
License Law does not apply to an ownerefpropeny whobuildsor improves thereon,and PERMIT ISSUANCE
whocoulmers fisrsuch projects with a contractor(s)Licensed purwanun the Contractors ALTER LA FEESUMMARY
License Law. (o )
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
OSANITARY YN
Owner Date
DRAINS-FLOOR,ROOF,AREA,CORD. RRCI:IPf p
WORKMAN COMPfiNSofcon DECLARATION SCI{001,TAX Y N
❑Workers
Co aRirmthatnsuracI have eor a0eneed copenztoof(Secure,or Lab C.)ate ofwhich RECI:I PIN
Workm'Compensamanlrurunce oracenified copy thveof(Sm.3g00,Lab C.)which FIXTURES-PER TRAY PARK FEE Y N
covers;all employees under this permit. RECEIPT p
Pm1!(nic
GAS-EA.SYSTEM-I INCA OUTLETS
BUILDING DIVISION FEES
:fed copy is hereby furnished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ ified copy is tiled with the city inspection division. GREASFJINDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
section need not be completed ifthe permit is formic hundred dollars($100) SEWER-SANITARY-S'I'ORM EA.200FT. ENERGY FEE
mess.)
I cerilymia in the ficommummccofthe work for which this permit is issued,[shall WATER HEATER WNENT/ELECTR
not employ any person in any manner sat as to become subject to the Wrkers PAID
Compensationlawsof Califamia Dam WATER SYSTEM/MRATING
Applicant Date Reeeiptp
Q z
z C) NOTICE:TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL
rom.~�. bece sam m bjethe Worker's Compensation penion pric,moas of the Labor Code,you most
C4 > forthwith comply with such provisions or this permit shall be deemed mvoked. BUILDING FEE
y Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm than there is a construction lending.gooey for the performance of
U O the work for which this permit is issued(Sri.3097,Civ.C.) TOTAL ELECTRIC ITE
Lender'a Name !PAID
NG FEE
O U Lenders Address QTY. MECHANICAL PERMIT FEE
I cmify that 1 have read this application and state that the above information is ICAh ITE
�"' 0. correct.I agree to comply with all city and county ordinances and scam laws mining m PERMIT ISSUANCE ��
building construction,and hereby authorize representatives ofthiscity to enter upon the
U Z aMwcmemioned p-,city for inspection purposes. ALTER OR ADD TO MECII, CTION TAX
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabif tics,judg ems,cruandexpenses which may in any way ucrvengainn said City AIR HANDLING UNIT(TO 10,00)CFM)
e !the gmnlingm permit.
AIR HANDLING UNIT(OVER 10,000 CFM) Ii
Si cnnwrc of Applies m0acmr me a(s EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITOU 10L"BTU) Dam Reeei
Will the applicant or future building occupant store or handle haardous mammal
as definedHEATING UNIT(OVER Ifq,ODO BTU)
by the CnPcrtion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Samba 25532(a)'I
11 yes El No VENTILATION FAN(SINGLE RESIDE
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
Will thenconcations redefined by he Bay Area Air Quality es
ant �f A I D
havNous air mntaminams us defined by the Bay Area Air Quality Manegemcm BOILER-COME(OVER 100,000 BTU) Y- i1
Dlstriat't 1i
❑Yea ❑No NEW RESIDENTIAL MF,CI{. SQ.FT. 11101/ O 1993
I have read the hvmdous materials.,at.mems under CTaNpmr 6.95 of the IIv 993
California Health&Safety Code.Sections 25505,25533 and 25534. I understand that C1 VT' t/U�CfiI IIYk
ifthe building does not cummily have a�cama,that it is my responsibility to notify the
oc c.,unt of the reyuimmcma which most be met prior ,,i....rce of a Cenifiwte of
Occupancy. za
Owner or amhorized agerDate ISSUED BY:
OFFICE