25864APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING- ELECOGUAL
CITY
- PERMIT NO.
OF CUPERTINO
APPLICATION/PERMIT PLUMBING - MECHANICAL25864
• BUILDING DIVISION r BUILDING PROJECT IDF.NTIFICATI(3N
WILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBBMMIITTALLDATE
1 e ✓ UNIT is LOT#
1
1WNERSNAME: PHONE: CO TRACTOR'S NAME: IC NO:
NIC
CONTROL#
'42—N
❑
CHITECT/F.NGINEE LIC NO: AD15RESS:
CONTACT': PHONE: QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG E ECT PLUMB MECH
'JOBB\OESCRIPI'ION
PERMIT ISSUANCE
at
10
)C
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALl
Thereby ofrntctlamllce sed Bmiradapm Professions Czlk,nd (commencing with
Section ]000) BDivision 3 of the Busine;aand Professions Code, and my license is in PANELS
full force and effeet. f G'
-
�a �I
l.ioem C Lia UP TO 200 AMPS
' y
Da Convacmr 201 - 1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records. OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
O
�,
1
SIGNS ELECTRICAL
'
Licensed Professional
IU
OWNER -BUILD DECLARATION SPECIAL CIRCUIT/MISC.
.F
I hereby affirm that I am exempt ffr from the Contractor's License Law for the
following reason (Section 7031.5, Business and Professions Code: Any city orcounty TEMP. METER OR PoLE INST.
o
which requires n permit to construct. alter, improve, demolish, or repair any swcture
1C)
�
u.
,y
G
;�
prithe it, licensednnlsorel to the prvisiosocart fthe ch Copemtigo License La statement POWER DEVICES
that he is licensed with Sectio to the) of provisions of the Ce Burin is License Ixw (Chapter
9(wmmenclog whh Section 7000) of Divislon3of The Business and Professions Code) SWIMMING POOL ELECTRIC
or that he is exempttherefrom and the basis for alleged exemption. Any violationof
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS -SWITCHES -FIXTURES
not more than five hundred dollars ($500). NEW RESIDENTIAL ELCCTR _SQ. FT.
I,mawnerofNe rt -
'❑ pmpe y,ormyemployees wilhwagesus[heirsolecompensation.
VALU
`7 �"�
1
STORIES
TYPE CONSTRUCTION
.�
will Jo thework,andte structure isnotiatendeJmofferedI ... le(See.9044, Business
and Professions Cade: The Contortion's License Law does not apply to an owner of
pmpertywhobuildsmimproves thereon, undwhodcesauchwarkhimselforNrnvghhis
employees,providedthatsuchimpmvementsarenotimendMorofferedforsale.If,
OCC GROUP
IFS UNITS
however, to building orimprovement is sold within one yearofeompletion, the owner- O
builder will have the burden of proving that he did not build or improve for purpose of AW
at.g.
❑ I, as ownerofthepmperty,emexclusively, contracting with licensed convectors to QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
consumer the project (Sec. 70t44, Business and Professions Code:) no Contractors PERMIT ISSUANCE
License Law Joesnot applym an ownerofpropetty who builds orimpmvesthereon,end
who contractsforsuch projects with acontrmons) licensed pursuant to the Carmelites ALTER - URAL WATER (EA) License Low. )
FEE SUMMARY
❑ I am exempt under Sec. , B & P C for This reason Fq,OW PROTECT. DE CF.
OUTSIDE FEES
SANITARY YN
Owner Date
RECEIPT #
WORKMAN COMPENSATION DECLARATION DRAINS -FLOOR, ROOF, AREA, OND.
SCHOOLTAX Y N
❑ Thereby affirmtatl huvencerificate of wnsem mulf-insure,... certifcateo
Workers'Compensiumn Insurance ora certified copy thereof(St (St. 3800, Lab CJ whi FIXTURES - P
RECEIPT#
PARK FEE Y N
coven all employee's under this permit. GAS - EA. -1 INC. ETS
Policy #
RECEIPT#
BUILDING DIVISION FEES
Company GASYSTCM-OV ( A)
Certified copy is hereby faed.
❑ mish kX
PLANCHECK FEE
GRADING FEE
❑ Certified copy is filed with the city inspection division. GREAS TRL TE I ]`TOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETR P
SOILS FEE
COMPENSATION INSURANCE
ENERGY FEE
(This section read not be completed ifthe permit is for one hundred dollars (SIM) SEWER - SANITARY - STORM EA. 200FT.
or leas.)
I cerify that In the performance ofthe work for which this permit is issued, I shall TER HEATER ENTIFLECTR
not employ my Person in any manner so as to become subject to the Workers'
PAID
Compensation Laws of Califomia. Date WA RSYS /TREATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should NEW uIdENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Cade, you must
forthwith comply wit such provisions or this permit shall he deemed revoked.
BUILDING FEE
a
CONSTRUCTION LENDING AGENCY
SEISMIC FEE O
I hereby affirm that there is a construction lending agency for the performance of TOTAL:
Ne work for which this Permit is issued (Sec. 309], Civ. CJ
Lender's Name
ELECTRIC FEE
Lender's Address - QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify Nat I have read this application it state that the above information is
correct. Iagree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives ofthis city to enter upon the -
shove -mentioned property for inspection puryDse4. /) ALTER OR ADD TO MECH.
(We) agree to save, indemnify and kEp, harmless Ne City f Cupenino against
Iiebililies,judgments,$o's andexpe htehmey.in myweyecO. .gamut id City AIR HANDLING UNTT(TO 10,000 CFM)
ce ft E anti (�i' Pe 'it.�
CONSTRUCTION TAX
/ AIR HANDLING UNIT (OVER 10,000 CFM)
f _ _ f
PAID
Date Receipt#
Sigrammof p,lican fict r' ale EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 100,000 BTU)
TOT
► a,
`1
Will the applicant or future building nccupsnt store or handle hazardous material HEATING UNIT (OVER 100000 BTU)
The Health and Safety
as defined by the Cupertino Municipal Code, Chapter 9.12, and N ,
Code, Section 25532(x)7
11 Yes ❑ No P.NVTILATION FAN (SINGER RESID)
ISSUANCE DATE
BOILER - COMP (3HP OR 1(q,000 BTU)
equip
Wusai appncanations rebuffing
PAID A I D -
by he Air Quaevic Management
hazardous air contaminants as defined by the Bey Area Air Quality Maziagement
Dlsulct7 BOILER - COMP (OVER 100," BTU)
❑ Yes ❑ No NEW RESIDENTIAL MECH.—SQ. FT.
1 have read the bamodous materials requirements under Chapter 6.95 of the
JAMB 6 7994
l�
Continuum Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
ifthe building does not curten0y have a tenant, Nat it is my responsibility to notify Ne
y
Cl 1
V Ut UUrrhI INU
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
ISSUED BY: V l/��►]I
Owner or authorized agent Data TOTAL:
OFFICE