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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
B ILDINU-EL,CI'RI A[.
BUILDING PROJECT IUEN'I'IRICATION
PINGPROJECT]DLUMB NO - NI IFIL
PERMITNO.
25436
BUILDING AIVESS:
{\s•�(�17�(L1J
UNIT #
LOT #
SANITARY NO.
APPPPyLIIG'1]ON
�SSUB�MII11 A]. DATE
T .k_ � r 30
V
OWNP A '' c 1 �/�P yF�a�
["lA` {� 1`\l L/ \l `
CONTRACTOR'S NAME: LIC NO:
e p
J
NIC
❑
CONTROLp
ARCHI'I I.CI'/17NGINEER: LIC NO:
A 'SS'. Ik'C
CONTACT: PHONE:
QTY.
ELEC7RI PERMIT
FEE
BUILDING PERMIT INFO
LDG ELECT PLUMB MUCH
PERMIT ISSUANCE
❑ El El
LICENSED tatIcensedkACrOR'SUECLAk pter9 with
1 hereby nffDi Nall amlicensedinessa
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
andChair9(commencing
SectthreeandnfDlvision3of the Business and Professions Code. and mylicenu is in
f rorre and effect.
Lic. It
UP TO 20B AMPS
Dare �rECTS
201 .R
III AMPSFT
DECLARATION
understand erstand my Idiotism)[ bravados public records.
OVEContractor—
OVER AMPS
REA
' O AQL D I p[ S/SQ.IT.
N ,
SIGNS ELEELECTRICAL
I'��—�a
U TER
Li«nsed Professional1`0M
OWNER-BUILDERDECLARATIONSPECIAL
CIRCUIT/MISC.
I affirm That I am exempt ,ram the Contractor's License Law for the
O
'11iMP. METER OR 1'OLF. INST,
r,hroch,nr.. (Section
followingmo,
Professions Cwtc: Any city.,mosimy
t, OR,, land
a.
which construct, alar, improve, demolish, rcpza any swcturc
s a permit re nares
DATE
POWER DEVICES
its ass i me file statement
prior toslicensed rvisios for
purotnt tothe provisionsthesuch Copamitmfileese La
mthe of Di w�of the Contractors and Prrlaw(shaper
thea heisncing with
9(commencing with Section ]0(0)ofDivision 3 o the Business end Professions Cade)
or that he is exempttherefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicani for a permit subjects the applicant to a civil penalty of
—Jt
SWIMMING POOL ELECTRIC�
VpLUA
/ 0 —_
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars ($50)).
NEW RESIDENTIAL ELECTR _SQ. T.❑
STORIES
TYPE CONSTRUCTION
wiIIdo Newark,and the sm chum, isnot intendedoroffered fee We (Sec.'E 14, Business
and PtnfieW... Code: The Comarors License Law does not apply to an owner of
propcny who buikhorimprovex therson.and who does such work himselfarthrough his
employees,providednproverert
intendedaof or offered forthe
OCC GROUP
RES. UNITS
'TOTAL:
is scmanhorene
owner-
however, We building or improvement is hath within one year of completion, proer the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY.
PLUMBING PERMIT
FEE
❑ hasownerof thepropenY.am ex<lusiv<ly<onuacting with lic<rtsed contranorsm
FLOOD ZONE
APSE
construct the project (Sec. 70G4, Business and Professions Coda) The Contractor's
License Law does not apply to an owner of property who builds or improves thereon, and
PERMIT ISSUANCE
whocantruas for such projects with a conorcums) licensed pursuant lothe Contractor's
License law.
ALTER - DRAIN &VEMI'-WATER LA
(')
PEG SUMMARY
❑ 1 no exempt under Sec. . B & P C for this reason
BACK FLOW PROTECT, DEVICE
OUTSIDE FEES
SANITARY YN
RECEIPT#
Owner Date
DRAINS - FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherehy uffnn that)havcucenifcatc ofamscnnoself-in sure.... a rrnifcatcof
WorkersCompensation Insurance or a certified copy themof(Sec. 3800. Lab CJ which
cover, all employees under this permit.
Pol cy #
RECF.IPP#
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM -I INC.4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEF.
❑ Certifrdcupyisherrbyfum,lim).
GREASEIINDUSI'RL WASTE INTERCEPTOR
GRADING FEE
❑ Condicd copy ih filed with the city inspection divislay.
CERTIFICATE OF EXEMPDON FROM WORKERS'
GREASETRAP
SOILS TEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200IFT.
ENERGY FEE
(This section need not becompleted ifthe proof is forone hundred dollars IS IBO)
or less.)
WATER HEATER W/VF.NT/ELECIR
I¢nifymm irme performance fthe work for whichmi., runit is issued, l hhall
not employ any Person in any manner so ss ser become subject to the Worked
PAID
WATER SYSTEM,7REATING
Compensation Lawsof Colifomia. Dae
Dae Receipt#
Applicant
NOTICE I'O APPLICANT. If. after making this Certificate of Exemption, you should
NEW RES] DENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Irk for affirm Nur them, is issued(Sm. 34lending agency for Ne performance of
Ne work for which this pcnnit is issued (Sec. 309]. Civ. CJ
TOTAL
ELECTRIC FEE
tenders Name
Lenders Address
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify That i have rend this application and slam that the above information is corrMECHANICAL
l agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
FMect.
building co.tar«tion, and hereby amhmimerepreaenmtives of Nis city wenterupon the
above-mcmioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(Wc) agree w save, indemnify and keep l amdeas the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accrue against said City
AIR I IANDLING UNIT (TO 10.000 CFM)
in asequence of the granting of this Permit.
AIR HANDLING UNIT (OVER 10.000 CFM)
gnummu Applican .moctor C1"` Datc
EXHAUST GOOD(WMUCFE
PAID
HEATING UNIT (TO I0QOo0 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
HGTING UNIT (OVER 100,00) BTU)
TG'1'AI'
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and SafetyI
Cale. Section25532(u)]
0 Yes ❑ No
VENTILATION FAN (SINGLE RESIDE
ISSUANCE DATE
Will thcappli<ant..rfuwmbuipding«cupanmuequipmem ordeviceswM1ichemit
BOILER - COMP(JHP OR IW.t)tXI BTU)
BOILER -COMP (OVER I00,fkm BTU)
hmardous air turnarounds as defined by the Bay Area Air Quality Management
Dimricrf
NEW RESIDENTIAL MECH.—SQ. FT.
11Yrs El No
fl— A 6
I have read the M1vardaus matenith requirements under Chapter 6.95 of the
California llealth & Safety Codr, Sections 25505, 2553] and 25534. 1 understand that
if the building does not currently have a tenant, that it is my ov,maihility to notify the
«upam or rhe rcyulrcntcme wM1lch must hl mot prior m ixsuan« of o Cenifeutc of
p0 O
y
C/,
Occupancy.
Y r
ISSUED BY. EU
Owner as munmosil agent Date
TOTAL:
OFFICE