25120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDIN ..ELECTRICAL,- PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL L/J 5 � /J 0
BUILDING DIVISION BUILDING PROJECTIDENI IFICAI ION J G
BUILDING ADDRESS: Gr Li P<k piif v SANITARY NO. •aA�I`'1.'LICATION SUBMITTAL DATE
l 13 1 (_ L M I— C\ UNIT# LOT#
OWNI' SNAMf� `` PHONE CO TRACTOR'S NA F:: LIC NO:
VQ. ^II SC 'ESS -14 7 Z V' r k"- C.S 9 2oj NIC coNlxOL#
ARCITRCT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONI?:
QTY. ELECTRIC PERMIT FEC BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE N1Y1 El E
LICENSED CONTRACI'OR:SDECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
F100cwz Ihereby ofrnslhatl 3 ofth Businssan Profession runc,Cosle.=it mmocense with
�00 SeniorceandJof Division].!Ne Business and Professions Code.wd my license is in PANELS J\\
mFU. full force and effect C, �I
<IY1 Liccnu Class�Lic.p "' 1 ��'b � UP T02o0 AMPS
F G'y Date Commemr 201-I"AMPS
ZOy— A RCH I'I'EC'I'S DECLARAI ION OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.PT.
O Z—O I understand my forestial be used as public records n n
FceFm l SIGNS ELECTRICAL V— In`r'1 /� ^ ^ D ' N
Licensed Proflessiona
�ta:=< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �I
°•OyU I hereby aflinn ihtn 1 am exempt from the Conoacmfs License Law for the ) g
�a0 ei following reason.(Section"1031.5,Bmand inco, Professions Code:Any citymcmimy TEMP.METER OR POLE INST. ,{ �.- I� g
issuance, the applicant for such Permit}7 prior to i< which requires a permit to consumer,alter,improve,demolish.or repair any structure,
5r� ts tto file a signed statement
POWER DEVICES
WC<pz that he is licensed pursuant to the Provisions of the Contractor's License law(Chapter
ca. 9(commtion,with Section 9000).1 Division J.INe Business and Profasinns Code) SWIMMING POOL ELECTRIC _ n —VAI
`U
.,that he is escraps therefrom andthe basis forth,alleged exemption.Anyviolidim of QUTLETS-SWITCHES-FIXTURES 4p/Y^1
F-Za Section 9113 L5 by any applicant for a permit subjects the applicant to a civil Penalty of
tot more than five hundred dollars($500).
Co ❑ LasownerofNepmpcny,.rmyemployeeswirh wagesas theirmlecompcnsmNEW RESIDENTIAL ELECIIt ion, _SQ.Ff. STORIES TYPECONSTRUCI'ION
will dothe work,and the structure isnot intended or offered for sale(Sec.Jl1D.Business
and Professions Code:'Ihe Contractor's Licenm Law does not apply to an owner of
prop,ny who buildsor improves Nerenn,andwhod«s.such workhimselforthrough his OCC GROUP RES.UNITS
employces,provided that such impravememar
s e not i mended ser offered outside.If.
however,the building or imprnvUmenr is sold within one year.!completion,theowncr- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose.(
sale.).
❑ Las owner.fthe property,am exclusively contracting with licensed comtracmrs m QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.90f 4,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License law does not apply to an owner of property who bolIds or improves therem.and
who maraca fofsuch projects with a contraction)licensed pursuant to Ne Commodes
License Law. ALTER-DRAIN&VENT.WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,tl&1'C for this rcmon BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT'DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby aflinn thalhaveacenifcate.fronsemmself-in.wr,,nracenifcate of FIXTURES-PERTRAP RECEIPT'#
Wmmm'Compensntlnn Insurance or ucenlEed copy these.[(gee.3PIl0,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS R17CEEM#
Policy# BUILDING DIVISION FEIS
company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ITL
❑ Certified copy is hereby famished
❑ CenilieJ copy's tiled with the city inspeminn division. GREASE/INDUSTRL WASTE INTERCEPT OR GRADING M'E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection."dnot be completed iffle permit is furore hundred dollars($100) SEWER-SANITARY-Sl'ORM EA.2001717. ENERGY EF,Ii
or Icsa.)
I ccrify that in the perfamanceof the work for which this permit is issued,I shall WATER HEAT ER WJVENT/ELECTR
not employ any parson in any manner so as to become subject to the Workers' PAID
Comlimettionlawsof California. Date WATER SYSTEWDUE TING Dae Racipt#
OO NoIII]CH 10 APPLICA NT:If,after making this Ceni ficmc of lixcmption.you should NEW RESIDENTIAL PI.MB. SQ.FT.
cant
Z, .. 8 TOTAL:
F' become hwithc copy the such provisions or this pnwisiuruofedremeLabor Code,you muse
a �
forthwith comply with such provisions or permit shell be deemed revoked. BUILDING FEE �+
W (� CONSTRUCTION LENDING AGENCY SEISMIC FEETO
z Ihereby affmnhat there iso crnntruclin.leadingagency for the perfomume.of ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name
O U I e Lcnd Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
cnify that 1 have read this application and stn¢that the above information is
>" a c meet. In agree to mm 1 with all cit and count linances and state laws relatin m PERMIT ISSUANCE MIiCUANICAL FEE
g comply wi city county g
VF-' Z buildalsovengrotioned construction,and wordy authorize repeves. fives of this city menmr upon the CONSTRUCTION TAX
z above(We)agree property find inspection and keep.ses. ALTER OR ADD TO MECN.
(We)agree to save,indemnify and which
harmless the City of a aganino against
liabilitics,judgmena,cosrs andexpcnux which may in any way azcrue against said City AIR HANDLING UNIT(TO 10,00)CFM)
in ce oft c ntingof thisprrome- 999
1 /^ AIR HANDLING UNIT(OVER I0,000CFM)
Signature.(ApplicanUCmarrumr D [J
EXHAUST HOOD(W/DUCI}
lip
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(10 BTU) Date Receipt#
Wit I the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,003 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the health and Safety
Cale,SectionElYet ❑No 23532(.)+ VENTILATION FAN(SINGLE RESID)
❑
ISSUANCE DATE
Will thea applicant building occupant mrdeviceswhichemit BOILER-COMP(3HPOR lUl1,IIBp BTU)
PD Van yuipmen
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IIX1,008 BTU) fR
Distri.fl {^e
❑Yum ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hanurdous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
Hthe building does not currently have a tonant that it is my responsibility to notify the !s
occupant of the repo mmems which man M met prior to issuance of a Certificate of e��Ir
Occupancy.
Owner or authorized agent Dam TOTAL ISSUED BY: Yf