25151 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIILDINO.RE.ECFRICAI- PERMIT"°. 25151
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDEYI ur'II:A'fIi1N,-
3
BUILDING ADDRESS:n SANITARY NO. API'LICA'f10N SUBMITTAL DATE
(JSO -` WI'WI'IA t9,UNITp LOTH I Gsa•'2./C(
OWNS NAME: , PHONE: CONTRACTOR'S NAME: LIC NO: NAC CONTROL It
E
CI TFQiCpENGI F, � LIC NO: AD S:
OR1ES�/ � s ❑
TJ \ O/
CONTACT: APHONE: g+l
T7 «V Q'IY.�, q I$q„ �GCTRIC PERMIT FEEBUILDING PERMIT INFO
'- BLDG F1EC1' PLUMB MECIi
T(/tJ
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Qmz I hereby affirm that l am licensed under provisionsm'Chapter9(commenciagwiW
lWOO Section 7000)uf Division 3of the Business and Profeseinna Code,and my license is in PANELS },O ��ry\�j/
Fy.?� full force-deflec,� �e�L �� / UP TO YOIIAMPg �/pj \ W�/V\`i
QQ ZZ,,ty License lass Lic.p "'-`�-C
sFia6y
Date
Cnmrazmr 301.1000 AMPS
Z O,z ARCHITECTS DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
OZ-0 1 understand my plans shall be used m Public records.
1:.y SIGNS ELECTRICAL
Licensed Professional
is OWNER-HUILDLR DECLARATION SPECIAL CIRCUIT/MISC.
�OyU I hereby affirm We,1 am exempt from the Contractor's License law for the
W 3 a rn following reamn.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires apcom to carouser,slier,improve,demolish,m repair any structure
W rt
` N� p000 its issuance,also requires the applicant for such pernitto file a signed statement POWER DEVICES
Bj 0 p that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter
4 C 9(commencin with Section 7000 f Division 3 of the Business and Professions Code SWIMMING POOLEL.ECIRIC
oµ, (commencing )o ) VALG
y❑y onhathelsexerapn curromanJ the hxsia for the allege)exemption.Any violation of OUTLETS-S CHF.S-PI S ^ 1 DO
QScaion 7031.5 by pay applicant forapenniuubjects We applicant mecivil penalty of (�
not mom than five hundred dollars(5500).
NO ❑ I,asownerofthepropcny,ormyemployceswiWwagessstheirsolccompmation, NEWRPSIDENTIA ECTR SQ. STORIES 'TYPE CONSTRUCTION
y3— will date work.and the structure is intended proffered for sale(Sec.704L B minas /
and Profession.Cale:The Cattleman's License I.aw does not apply to sn owner nI
property who buildsorimproves thereon,andwhodocssuch work himalfanhrough his
OCC GROUP RES.UNITS
employees, m,nied that such improverecnksae not l nrendedoroffered forsals.If,
however,the building orimpmvemml is sold within one yea ofmmpletion,mamenm- TAI
builder will have the burden of proving that he did not build or improve for purpose of t
sale.).
❑ I,ns ownerof the property,an exclmivelyearancting with licensed conordemnta QTY, PLUMBING PERMPP EI? FLOG°"LONE qPN
compact the project(Sec.7044,Business and Professions Code:)The Contractor'
License Law Wormy apply toamawnerofoomy who builds.,improves thereon,and PERMIT ISSUANCE
who contracts forsuch projects with xcanlmctor(s)licensed pursuant o the Contractor's AIfTER-DRAIN Nc VIiNT-WATER TA
License Law. ILA) PEE SUMMARY
❑ 1 am exempt under Sec: ,N&P C for this rtason PACK FLOW PROTECT DEVICE ID, ,1.
SANITARY YN
Owner Dam RECF.IPT41
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ Thereby affirm that lhave acertificate of consent mull-insert,ora certificate ofRF.CEIPI'q
FIXTURES-PER TRAY
Worken'Cnmpcnsctionlnaunnce nrucenified copy thereof 05m.3g00,LabCJ which PARK fIeLz YN
cover,all employee's under this permit. GAS-LA.SYSTEM-]INC. OUTLETS RECffl"#
Policy p BUILDING DIVISION FEES
Company GAS CA,SYSTEM-OVER 4(EA) PLANCUI:CK FEE d
❑ Certified copy is hereby famished.
❑ Certified copy is bled with the city inspection division. GRIb15FJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CINO IIICATF.OF EXEMPTION FROM WORKERS' GRHASETRAP I SOILS FEE
MMP17NSAT'ION INSURANCE
This section nceJ not he completed ifthe permit is for one hundred dollars L$100) SEW13R-SANITARY-STORM EA.200M. ENERGY FEE
mless.)
I certify that in We performance of the work for which this permit is issued,l shall WATER HEATER W/VENIELECIR
not employ any person in any manner m as to become subject to the Workers PAID
Comperowionlawsaf Cabomu. Data WATER SYSTEMRREATING Use Receipt If
Z Applicant
O0 NOTICE TO APPLICANT:If,after Making this Certifaamof Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. 'TOTAL:
V) become subject to the Worker's Compensation provisions of the labor Code,you must -
7 forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
0. 7; CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby effiw that Were is a construction lending agency for the perfowsnce of
O the work for which this permit is issued(Sm.3097,Civ,C.) TOTAL: ELECTRIC FEE
tr Lenders Numc "e'*
C.7 Lenders Addresx QTY.- MECI IANICAL PERMIT PH PLUMBING PIAT
I Cen ty the,I love read this application and smie We,the above information is
W cermr.l agree to comply with all city and county ordinances and amen laws elating to PERMIT ISSUANCE MECHANICAL FEE
F" V) building construction,and hereby umhurim representatives of this city toenerupon the CONSTRUCTION TAX
U Z above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep hardess the City of Cupertino against
liabilities,judgm ors and expenses which mayinnnyway mcImagyns aid Cit AIR DANDLING UNI'1'(TO t0,000CFM)
in cons vetting of this pewit G
h AIR HANDLING UNIT(OVER 10,000 CFM)
)
Sigraare of ApplicanUCon pr D EXHAUST HOOD(W/DULT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Iflat81f1 BTI) Date Receipt 0
Will the applicant or future building mcupau store,r bundle iozamom me,crieI
.omfinedhythe Cupertino Municipa Gdt;Chapter9.13,andihe Heallb.,i Safety HEATING UNIT(OVER 1!10,1100 BTU) 11gp�� TOTAL:
Cade,Section 25,532(a)? VERI'ILATION PAN(SINGLE RPSID)
❑Yea No
Will thea licentarfuere buildin mese BOILER-COMP(3HP OR Iffy"BTU) ISS NGF.DATE
pP B Pant tnoto ardevica whi<hcmit ��� a 1993
ao p�Tf,
hazardous air contaminants as de0xed PBM,Ates Air no.
Manegenlenl BOILER.COMP(OVER 100,000 BTU) pVVs/
Dindctp J
❑Yes o NEW RESIDENTIAL.MSCI I. SQ,Kf. C�''1 N
UUf t/111 Q
1 have reed the hazardous materials requirements undo 34.Chapter
un 6,95 t of We N
CaliforniabulinHealtho s Safety CodaSections
have
t 35505,t it is and 35534. 1 understand that
/iT theant of t e requirements
m nts wI have a meant,that it is my responsibility a reify the L'
O cupant of the rtquiremcno which must be met prior to issuance of a Cenificute of
Occupancy.
Owner.,uahmivml agent Dale '10PAL: ISSUED BY: /'V� • 1