25536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUI.DI 1:-h.1.ECTRICA I, PERMI'T NO.
PLUMBING 'MECHANICAL
BUILDING DIVISION BUILDING PROJECTI/EN'TIFICA TION 25536 JJ36
BUILDING ADI) 'KESS: � UNIT# LOTH SANITARY NO. APPLICATION SUBMITTAL DATG
OWNL'Rf^SL/NAAAMMEEJ: 1 PHONE. CONTRA 'S NAME: LIC NO:
Pim 1. /fir / Llns CJ, /2�� NIC CONTROL#
•AR 1119E / GINflUR: "V LIC NO: A ESS:ati J �—/r'1 6 -�/
ti' #v n orae b Ss mow, 7O.
CONTACT: Ao^m Lk BUILDING QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
` L ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Mzz I heebyaffimr that l am liccmed underprovisionaof Cbapmr9(commencingwith TOB DESCRIPTION
[DOGE Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
KUU Licarefall aeanAeffect.
�ZNI License Clncs hie.# UP T0200 AMPS
N 6 y Date Contractor 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 100(IAMPS SQ.FI'.FLOOR AREA S/gQ.FT.
O Z—G I understand my plans shall beuaed ss public recnrda.
l-y F W SIGNS ELECTRICAL
Qy j Licensed Professional
LC od< OWNER.BUILDER DECLARATION 1 SPECIAL CIRCUIT/MISC.
KOyF 1 hereby effiem that I am exempt from the Contractors License Law for the
tB3ta•m following reason,(Section 0031.5.Business and Professions Code:Any citymcounty, TEMP.METER OR POLE INST.
which requires upennittoconstruct,alter,improve,demolish,or repair
far
,}7 to its issuunce,alwrc the licant(or such
POWER DEVICES
prior quires pp Permit
BIC
aligned natemem
Wix G cC that he is licensed personal to the provisions of the Contractor,License Law(Chapter
t1 Qo p, 9(common,with Section9o0ff.rDTvialon Jiffies Business and Professions Code) SWIMMING POO(ELECTRIC VALUATION _
p r^y or that he is exempt herefrom and thebasis for the alleged exemption.Any violation of OUTLP,TS-
A G Section 0031.5 by any applicant fora permit subjects the applicant a civil pennily of SWITCHES-FIXTURES
AS not more than five hundred dollars($500). NEW RESIDENTIAL L•
a m [TI,osowneroftheprnperty,ormynnployms with wagesmtheiraolecompensation, STORIES TYPECONSTRUCI'ION
y w111doahework,und the mamas is no,unnamed reoffered Inrush:(Seer TM4,Business
and Professions Cede:The Contractor's License Law docs not apply to on owner of t t
propeny who builds or improves thereon,und whoduace uch wnrkhimsdfnnhrnughhis OCL'.GROUP. NES.UNITS
ownemployeee,provided rhmxnch improvements are not intended or offered forsale.If,
however,the building or impmvemenl is sold within one year of nimpletion,the rwrer- DATE -:A
builder will have the burden of proving that be did not build or improve for purpose of
agile.).
❑ I,asowneruflhepropeny,umexclueivelycontmclingwitblicrnx,l n.n actnram QTY, PLUMBING PERMIT FEE FLOOD ZONE. APN
construct the Inojert(Sea.70,P1,Business and Professions Codc:)'ITo Contractor's PERMIT ISSUANCE
License Law does not apply manownerofpropeny who builds or improves thereon,and
who contracts forsuch pro to with accoun tmr(q licensed pursuant to the Contractor's se law.
License
ALTER-DRAIN&VENT-WATER(FA) FEESUMMARY
❑ l em exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEE
SANITARY Y N
Owner Date RECEIPTp
DRAINS-FLOOR,ROOF,AREA,CONU.
WORKMAN COMPENSATION DECLARATION SCFIOOI.TA% YN
❑ Iherehy affirm thaal have mcenif¢am of conxnuo self-inure,oreanificerc of FIXTURES-PER TRAP RECEIPT is
Workers'Conforeation lnaumnce oro cenifiW copy thereof(Sea.3900,Lab C.)which PARK FEE Y N
ars all employee's under this permit. GAS-EA.SYSTEM-I INC. OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PfANCHECK FEELt(
❑ CCNBW copy is hereby famished. •
❑ CenifiW copy is Bled with the airy impeaion Division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CER'I'IFICATB OF F%EMPTION PROM WORKERS' GRFASETRAPSOIIS PEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollasa($100) SEWER-SANITARY-STORM FA.Ballet ENfiRGY FEE
or less.)
, I certify that in the performance office work for which this permit is issued,Ishall WATER HEATER W/VENT/BLECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Culifomia. Dam WATER SYSTENBREATING Dam Receipt#
zO NOTICE TO APPLICANT-If,after making this Certificate of Exemption, should NEW RMI DENTIAL PLMB. SQ.FT.
p ion,You TOTAL:
'Z Vj become subject o the Workers Compensation provisions of the Latin Cale,you must -
afanhwith comply with such provisions.,this permit shall be deemed revoked. BUILDING FEE as
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z `
^� I hereby aftirm that hem is a construction lending agency for the performance of TOTAL: ELECI'ftIC FF.I,
U pr the work for which this permit is i winal(Sec.3099,Civ.C.)
(•k, P Lenders Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE
U 1 cenify That I have and this application and stem that the above information is
0. correct.lnrzee ter coat with all cit and ordinances and state laws feuding to PERMIT ISSUANCE MFCI IANICAL FEE
6 comply yam county g
building utimunctinn,toed herebyamhorire reprcxcnlutivcsof@iscity to itineration the _
U above-mentioned property for inspection purposes. s ALTERORADDTOMECII. CONSTRIICI'ION TAX
(We)agree to,save,indemnify and keep harmless the City of Cupertino agui rest
liabilities,judgmems,costs and as pareses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in con acnes of the granting of rads m.
AIR HANDLING UNIT(OVER 10,(X10 CFM)
IS 3
Signamm of AM]eam/Contmcmr Dam EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,011)BTU) Data Reccipt#
Will the opplica d or future building terminal same or handle hazardous material
as defined by the Calandra Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(81 VENTILATION FAN(SINGLE RESID) �.
❑255 11 Na
Will theepplicam orfmumbuilJinga<upmm umeyuipmem ordevice.whichemit
BOILER-COMP(3HPOR 100,1100 BIV ISSUANCE DATE
hazardous air comaminants as defined by the Bay Area Air Qualify Management BOILER-COMP(OVER 100,000 BTU)
District?
❑Yes '❑No NEW RESIDENTIAL MECH.—SQ.FF.
1 have mad the Intimation materials requirements under Chapter 6.95 of the PAIL)California I Rabb&Safety Cede,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a amort,that it is my responsibility to notify the
occupant of the racuircromas which must be met prior to issuance of a Certificate of
Occupancy. P
Owner or auNodaed agent Dae TOL:TAISSU01 .
OFFIC Iva