25264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EL CTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25264_
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: 1 SANITARY NO. A/P'PLICAATIONNSSUBMITTALDATE
L UNIT# LOT#
OWNER$NAME:: PHON 51,11TRACTOR'S NAME: LIC NO: �P W
I i_:a. F � /L N/C CONTROLp
RCHITECT/ENGINEER: ,LIC O: ADDRESS: _ GJ ❑
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
qyy Ihereby affvmthat l am licensed under provisions of Chapter 9(commencing with
0.10 Section of Division 3 of the Business and Professions Code,end my license is in PANELS �
�W full forcer lend and effect.
l;20.,1 License Class Lia.# UPT0200AMM
V,6 Date Contractor 201-1000 AMPS
Z OyuARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O y,.q I understand my plans shall be used as public records.
YLicensed Professional SIGNS ELECTRICAL
K #
OWNER-B a.,,roof me Cmdr ION . SPECIAL CIRCUIT/MISC.
pk'Oy F -I hereby n.(Se that I am exempt from the Contractors License Lew for the
W 34w
following mason.Permit
to construct,
Business and Professions Co de:Any city or county TEMP.METER OR POLE INST.
L' which requireswi n permit m coastrucq inter,improve,demolish,or repair any structure
Np�'<0 prior to s licensed pursuant
t i the
tpe previsions
soom f the Co permi Contractors
fileLice si La statement POWER DEVICES
µl G O that he is licensed pursuant m the provisions of the me Business
License Law(Chapter
L o.' 9t(commencing
xemit therefrom
add the
Division Sof the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
' ,ern or Section
7031. by therefromnt for
basPermit
subjeasegedexemption. civiny l lathy of OUTLETS-SWITCHES-FIXTURES
Q Section]03 LS by any applicant(orapennit subjects the applican[loacivil penalty of
re than fivehundred dollms($SWI. NEW RESIDENTIAL ELECT* S Fr.
es: m Liesowmrof thepropeny,army employeeswiNwagesastheirsolecompensation, Q' STORIES TYPE CONSTRUCTION
L 11 do thework,andthe structure isnotiounded oroffered fmsale(Sce.]044,Business
J Professions Cade:The Contractor's License Law does not apply to an owner of
property who bu ilds or improves thereon,and who does such work himsel f or through his
ownemployces,providedthat such improvements we ndtintendedoroffered(Ortel¢.If, OCC.GROUP RES.UNITS
however,the building mimprovement is sold within one yearofcompletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ hmownerofthepropeny.amexclusivelycontracsingwithlicnsedcontmetomto QTY PLUMBINGPERMIT FEE FLOODZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Cc ad
License Lawdoesnotapply roan ownerofpropedy whobuilds orimproves thereon,and PERMIT ISSUANCE
whocommcts forsueh projects with acontraetor(s)licensed pursuant to the Contrmtur'e ALTER (PA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data DRAINS-FLOORROOFAREA, RF.CERTq
. , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm then have ecenifcme of consrntm self-insure,oracemificere of PIXTURPS-PF.R TRAP RECEIPT#
Workers Compensation Insurance or a certified copy thereof(Sce.3800,Lab C.)which PARK FEE Y N
c tact all employee's undenhis permit. RECEIPT GAS-EA.SYSTEM-1 IN040UTLET Punic,# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PI.ANCHECK FFP
❑ Certifiedeopyishcrebyfumished.
❑ Certified copy is Piled with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR _ GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the petmitis for hundred Mines($IW) SEWER-SANITARY-STORM EA.200FF. ENERGY FEE
or less.)
I certify that in the performance ofthe work forwhich this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any.antler so as to b'now,subject to the Workers PAID
CompensationLawsof Califomia. Dale WATER SYSTEMTRFATING Data Receipt#
O z Applicant
Z
0 NOTICE TO APPLICANT:IL after making this Cadmium of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FF. TOTAL:
V) became subject to the Worker's Crampemathin provisions of the Labor Code,you most
a5 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
O
^a I hereby affirm that hem is a construction lending agency,for she performance of
the work for which thisPni t is issued(Sec.3097,Civ.C.) 49 ELECTRIC FEE
C) rr Landefs Name
t' tinders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have rend this city
ad county
ty state that the above information is
building I agree construction,
and with all cityand countyotdtives osand state lawer upon gm PERMIT ISSUANCE MECHANICAL FEE
U4 buildingiwromformad property
hereby
spectonspurpses. Ives ofthiscity to enter upon the CONSTRUCIONTAX
(� xj above-mentioned pmpce, for inspection purposes. ALTER OR ADD TO MECH.
F7 (We)agree ntsave,indemnify and keep harmless y Cityco Cupertino id City
liabilitics,judgmen[s,costs and expenses which may in any weyecerue against said Ctity AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
— AIR HANDLING UNIT(OVER 10,000 CFM)
ss� e
are of Applicam/Contmcfor Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt*
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T T
as defined by the Canadian,Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532(a)p -
11 Yes 11 No VENTILATION PAN(SINGLE R85ID)
ISSUANCE DATE
Will the applicantorfuturebuildingoecupanrose equipmenmrdeviceawhichemit BOILER-COMP(3HP OR 100.000 BTU)
411�
fiazard as air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) r A I D
District]
11 Yes ❑No NEW RESIDENTIALMECH. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the JUN 25 1993
California Health e,Safety Code,Sections 25505,25533 and 25534. 1 understand that v
if the building does not currently have a redeem,that it is my responsibility to notify the
occupant of the requirements which must be,met prior to issuance of a Cenificme of CI Yr ur Gunn I i
Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY, Vs
OFFICE