25686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY f^�
CITY OF CUPERTINO BUIL DIN,-ELECTRI AL PERMIT NO, Z V H
APPLICATION/PERMIT PLUMB INO-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRiSS: SANITARY NO. APPLICATION SUBMn AL DAT
/ (,LEG M✓ UNIT# LOT'# I.
rMFNEIK NAME PHONE: CO gCTO AM � NO:
G / ' 7 / N/C CQNTRUL#
�AK II' /ENGINEER: LIC NO: AD .S: .� ��l ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT (� FE BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCH
El
PERMIT'ISSUANCE � E'er
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL /ly`J
I hereby affirm that l am licensed under p ( gwith JOB DESCRIPTION
WC'Z yes provislonsof Cha ter9 cmmmrnein
WOO &,imn]t]oB)of Division the Business and RvPossions Codc.and my license in PANELS s
neU fd1mr.and r
,ZW License Cl_s Lic.x ' UP T0200 AMPS s
..Qy Duce Cwtra,m / I�Ky, 2U1-Itl(q AMPS
�1:D CHTFECTS DECLARATION (� OVER 1000 AMPS SQ.FT.FLOOR AREA $/-SQ.FT.
O z—c I understand my plans shall be used as public records.
,..�
F rn�; SIGNS ELECTRICAL
2 �, Licensed Professional
P ro,MU OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MIS,.
XOd 1 hereby afEnn that 1 am exempt from the Comncmr's Licenu Law for the
WLLpy followingrensun.(Section 7031.5.Businemand Professions Code:Any cityttrcounty TEMP.METER OR PO INST.,, •' .,1 1� '`, II 1� h �J
O< which acquires to .it no consw,,alcor,improve,demolish,or repair any,mclure
WWY:Z prior to itsissuance,also requires the applicant for.such permit to f le a signed statement POWER DEVICES I
w M p O that he is licensed pursuant to Ne Provisions of the Contractor's License Law(Chapter
as 9(mmmemaln with Section700(nof Division 3oflhc Bumens,and Professions Code) SWIMMING LELERIC
CT
gwiyvim ) - VALUATION
room,
m—mhe isexemPFlherefromand the basis for alleged carni An lotion of OUTLETS-S ITCtIF3 FI RFS—
t-z Q Section 7031.5 by any applicant for a pertain subjects the applicant to a civil penalty of
nonmme than rive hundred dollars($500),
NWRESIDFVTIALELECIR S .FT.
63 ❑ azwnofnhcpmp y,ormyemplomswiM1wagsastheirsolecompnsatim,
STORIS TYPE CONSTRUCT IOP
will do lbcwnrk.and the enenme is not intended moffe N for sale(Sec.]U44,Business
and Professions Cale:The Contractor's License Law does not apply no an owner of
prnpeny who buildsnrimproves thcreon,and whookm,such work himself ar thnngbhis
employees,povidWNansuchimpmvementsartnonimendedorefferedformle.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within oneyearofcompletion,theowmco, TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
tele.).
E] I,u.ownerofthepropcrty,amexclusivetyeontueling lthlicensedeenoacmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
ewsw,the protect(Sec.7044,Business and Professions Code)The Convector's
License Lawdoesnot upplyioanownerofpropenywhobuildsorimprnvesthemon,and PERMIT ISSUANCE
whocomanc,a forsuch projects with a conuacroom licensed pursuant tothe Contraeoor's ALTER (, )
License Low. WATER FA FEESUMMARY
❑ 1 am exempt under Sm. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date SANITARY YN
DRAINS-FLUOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ (hereby afrirm ohm lM1aveacertiricme of ronum mself-insure,oruceruricum of FIXTURES-PER TRAP RECEIPT#
wroken'Compenmtionlmunntt oracenifiW copy nhertof(S«.JSIp,Lab C.)which PARK FEE Y N
rose's allempla '
mpa'yn n D noir i RECEIPT#
Polcyp '9 GAS-EA.SYSTEM-I INC.40UTLETS BUILDING DIVISION FEES
Company L
❑ GAS-EA.SYSTEM-OVER 4 TA) PLANCHECK FEE
Certified opy is�ereby famished. a
L1,16enifieJ copy is filed with the city inspection division. GREASEANDUSTRL WAS'TEINTERCErrOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(TTissecoionneadmalecompleted italicpemtitisforonehundrddollars(SIW) SEWER-SANITARY-STORM EA,.2MFT. ENERGY pill
or Ins.)
I certify that in the performance ofnhework for which this permit is issued,l shall WAILER HEATER W/VENT/F,LECIR
not employ any person in any manner so as no become subject no the Workers' PAID
Z Compensation Lawsof Califomia. Date WATER SYSTEM/TREATING Date Receipt#
Applicant
zO NOTICE'I'0 APPLICANT:If,after making this Certificate of Exemption.you should NEW RES IDENTIAL PLMB. SQ.FT. TOTAL
L- � become subjectto me Workers Compenmtiw provisions of the labor Code,you muco
Ca > forthwith comply with such provisions or this permit shill Is,deemed revoked. ,� BUILDING FEE
4 [;
CONS]RUCTION LENDING AGENCY SEISMIC FEE
2 1 hereby affirm that hem is a convection lending agency for the performance of
(� O the work for whlrh,his permit is is red(Sec.3197,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
OU Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify thin I base read this application and care that the above information is
correct.Iagr«to cmmply with all city eaW cowry ordinances and conte laws relating lm PERMIT ISSUANCE MECHANICAL FEE
F' Ce) building contrurima.and hereby a,M1on,representatives of this city no enter upon the
V Z above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify uad keep harmless he Cry of Cupertino against
Infladitin,judgmeres,costs and expenses whichmay in any way accrue against said City AIR HANDLING UNIT(TO 10,00)CFM)
inc a of the Standing of this pennin.
AIR HANDLING UNIT(OVER 10,900 CFM)
Signature of Applicano(Cmdommr Date EXHAUST'HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dane Receipt#
Will the applicant or futureuildingoccupant stow of handle hamrdoaz material
asdefiree by the Cupertino M mipul Cede,Chapo r 9.12,and the Health and Safety HEATING UNIT(OVER 100.0%B TOTAL:
Calc,Suction 25532(a)]
❑Yes No VENTILATION FAN(SINGLE SID)
BOILER-COMP UHP O .000 BTV) ISSUANCE DATE
Will nM1eapplicwnorfuwreb 'ding«cupwmuequipmem mdevices which emit pp��
hazardous air camariums is ns eOmeJ by the Buy Arca Air Quality Management gOILFR-COMP(OV 100,000 RTU) y
District?
❑Yes No NEWRESIDENTIMECH. SQ.ET.
I have read the hazardous materials requimmems under Chapter 6.95 of the MAR = 41994
Calimmis Health&Safely Cade.Sections 25505,25533 and 25534.1 undemwd nhao
ifnhcbuilding doesonly have a tenant,that i,is my rtspnnsibility m notify the
O,ecapant of me x met prior m issuance f a Ce ate of CITY Or Wrtri(inU
capon
Owner or mor mm agentLme
TOTAL: ISSUED BY:
OFFICE