25742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mar�iAz-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING�MECHANICAL 25742
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /� SANITARY NO. APPLICATION SUBMITTALDATE
`Ll II U UNIT# LOT#
OWNERS NAME: - PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONT OL#lll
�.S ) 2 10 1 Aj-All C N leer 6
RCHITECT/ENGINEER: LIC NO: ADDRESS:
PEI 30 ozoq (CGuerAc CA 251
corrrAcr: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
` BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I y s V F-1 IN El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
C9z I hereby affirm that lam licensed under provisions.fChapter9(commencingwith
F100 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS ( 66��
(&`;1vFKq y
az License Class C. 10 Lic.# b5rI S7 UPT02MAMPS
b full force and effect. TIL.///
tFn< Date Common,Al-All OU✓ 10 e1 201-IOW AMPS
`�
0zoti SQ.IT.FLUOR AREA $/SQ.IT.
ARCHTTECTS DECLARATION OVER 1000 AMPS
O Z^ 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Q ',�'..1 Licensed Prufessionnl
'S4 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°K10a I hereby from that I am exempt from the Contractor's License Law for the
W 3 LL rFii following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which reclaims a permit to consume[,alter,improve,demolish,or repair any sumc[us, -
�S�Y� Poroitsissuance,elsurequirestheepplic lfore�ehp.it tofile asigned sediment POWER DEVICES
that he is licensed pursuant m the previsions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
d 9(commencing with Section]000)of Division 3 of the Business and Professions Code) VALUATION
Moe, onwilm,iscamp,therefromandNebasis for the alleged exemption.Any vothemnof 3r ,
C Section 7031.5 by any applicant for u permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
m more than five hundred dollars($500). Q STORIES TYPE CONSTRUCTION
O NEW RESIDENTIAL ELECTR S .FT.
W m n❑ Las.wrk,ndtheanmromek kine hiteadeswithwagesesidei(Sce.compensation,
d will dot.,lon,Cde: he Comisrc int Leena how ffived
fursale(Sey 0094, eaec ss
of
and Professions Cale:The Contractors License Law does not apply to an owner.f
proper y who builds m improves thereon,add who dce s such work hin eel f or through his
OCC.GROUP RES.UNITS
wnemployebuldingrimprvemedealthat npis sold within one
console.If.
hewsver,the building orimpro prusim is sold within ane year or improve
for t purpose
of TOTAL: 1 17
builder will have the burden of proving that he did not build or improve for purp.0 of
sem.)' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ e as the pruftt(So.. rt , usi.c,velad Profetiio,with sedTh Cmitio[orslo
.menet the project(Sec.onno Business end Profession,Code:)The Cemod,urs PERMIT ISSUANCE
License Law does not apply to ec owner.(preperty w ho bu ilea m improv es thereon,and
whocontractsforsuch projects witharesuactess)licensed Panama,oidecticuremr's ALTER-DRAIN&VENEAT-WATER
License Law. .. ( ) FEB SUMMARY
❑ 1 we commit under Sec. ,B&P C for this reason OUTSIDE
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOFAREA. RECEIPT#
WORKMAN COMPENSATION DECLARATION . , . SCHOOLTAX Y-N-
I
NI hereby arfirm that l have a ceNficate ofeensent m self-insure,or a certificate of FIXTURES-PF.R TRAP RECEIPT#
Workers'Cgonmpeyrnattiioyn Insurance
eemma certified copy there.f(Sec.3800,Lab C.)which PARK FEE Y N
Poll ILl WCCLId)-Y)Y is GAS-EA.SYSTEM-I INCA OUTLETS RECEIPT#
BUILDING DIVISION FEES
ComponY 9 "mSr GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby furnished.
Certified copy is fled with the city inspection division. GREASE INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not completed ifthe permit is forme hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
.r les,.)
I emifythat in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in may manner so as to become subject to the Workers PAID
Compensation Laws of Califumia. Dale - WATER SYSTENErREATING Date Receipt#
ZApplica
ISI
0 NOTICE
O Z NOTICE TO APPLICANT:If,after making[his CertiFiwte of Exemption,you should NEW RESIDENTIAL PLMB. TOTAL:
r7 pj become subject to me Worker's Compensation previsions ofthe Labor Code,you mast
forthwith comply with such provisions.,this permit shall be deemed revoked. BUILDING FEE -
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
L) O me work for which this permit Is issued(Sec.3099.Civ.CJ TOTAL ELECTRIC ME
Lender's Name PLUMBING FEE
Q F Lender's Address QTY. MECHANICAL
W I certify that I have mad this application and stele that the above information is MECHANICAL FEE
correct.I agree to comply with all city and county ordinances and state laws relating to RMIT ISSUANCE
building construction,andhereby aomorim representatives ofhiscity to enter upon the CONSTRUCTION TAX
I U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO ECF
(We)agree m save,Indemnify akeep harmless keharmless the City of Cupertino against
ludelities,judgments,costs andexpenses which may in any way accemagainst said City A HANDLING UN 0, )
in consequence of the grouting of this Permit. �zt
AIR H DLING UNIT(OV 0,0(0 CFM)
Signature of Applicant/Contexter Date EXHAUS OOD ORMUCT) PAID D
HAZARDOUS MATERIALS DISCLOSURE HEATING U T(TO I0L000 BTU) Date � '-7
Will the applicant or future building occupant store or handle hivardous material HEATING USE OVER 100,000 BT TOTAL: gs (
as defined by the Cupertino Municipal Cods,Chapter,9.12,end the Health and Safety
Code,Section 25532(a)? VENTILATION FA (SINGLE ID) r
❑Yes ❑No
BOILER-COME(3HP ,000 BTU) ISSUANCE DATE
Will air communities
an defir of by the Bay equipmentQualit Marrachemi[ n A '
and u a cumnminan[s as defined by the Bey Area Air Quality Management BOILER-COMP(OVER IOO,WO BTU) P
isMct?s
4em
❑No NEW RESIDENTIAL SUCH. SQ,FT. iQ 1(](1 A
1s mat ills re ms under Chap¢,6.95 of me FEBtU '� IJ OY
Califuas e,S ns 25 ,2 33 and 25534. 1 understand mat
ifthen[ly v aten Jho t is my responsibility m notify the CI'.Y Ur vurr Cf111P1U
cupis w r must me rior issuance ofa Certificate oc up �•net t Date TOTAL: ISSUEDBY!w fl
OFFICE