25702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - a ILUI -ELECTRICAL. PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL
25702
BUILDING PROJECT IDENTIFICATION
BUILDING ADD''R'E)SS: '.U1 SANITARY NO. APILICIATTIIONS/UVBMITALDATE
�� I (o L/` • / 11v•ter, �INITa LOT# ! ��
An O NERS NAME: _ PHONE: TRACTOR'S NAME: ICN �r
6 e I f�n1 Cr NIS e,6 NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: QTY. ELECTRIC PERMIT FBUILDING PERMIT INFO
EE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
aZ
Iherebyaffirmthatla licensedunderpromsinnsof Chapter9(commencingwith
On Sation]IXNJ)ofDrvts' of the Business and Professions Code,and my license ie in PANELS "
W full force and a ee 7
�U
license Clas LIC.# UP TO 20s)AMPS
y Date Contractor 201-1000 AMPS
F y ARCHITECTS DECLARATION SQ,FT.FLOOR AREA S/S
O Z^O I undersmn my plans shall be used as public records. OVER 1000 AMPS
r� W SIGNS ELECTRICAL
Licensed Professional
c OC U
OWNER-BUILDER forDECLARATION Contractors
SPECIAL CIRCUIT/MISC.
O y U 1 hereby a.(Se that I am exempt from the Convector's License Lew.further
following reason(Semon 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Oy J which requires a permit to consumer,alter,improve,demolish,or repair any svuaure
poor m its issuance,also requires the applicant for such Permitto fileesigned smtemem POWER DEVICES
6 p that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
ax�V. 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALU/ LION.
iWCyy or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �C/
QSection 7031.5 by any applicant for a permit subjects the applaud to a civil penalty of
n0 l,are wn roftheive ToNny,red lormyem). o NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCDON
m ❑ ofhewrk,adthespeny,ormyempendedorrofwagesas Ne(See.compensation,
will PrAnsimk,Camw he Contractor is Licedoroff doesced r or apply 1. aBusiness
and Professions Code:The Contractor's License Law does not apply to an owner of
Property who hours orimproves thereon,andwho does such work himselfothrough his
ownemployess,providedthatsuch improvereentsare not intendedorofferedforsale.If, OCC GROUP RPS.UNITS
however.the building or improvement is sold within cane year ofecmpletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
a0 QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lae the no ,(Sec.7M4;;Business
onvaeations CodwmedeContramrsm
cnnswm the pmjen(Sec.]044;Business and Professions Code)The Contractor's
LicenseLawdoesnot
suchapply toamwaemmartorrtywho
ensed dsorimptothe Contracend PERMIT ISSUANCE
whense Lamafor such projects with econvacmr(e)licensed pursuanttothe Convector's ALTER-DRAIN&VENT-WATER(EM FEE SUMMARY
License on ex
❑ 1 am exempt under Sec. ,n&PC for this reasonOIJT
BACK FLOW PROTECT.DEVICE " FE S
Y
SANITARY N
Owner Dem DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have a certificate ofconsent to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
Worket%Compensation Insurance or a eenified copy thereof(Sec. Lab CJ which PARK FIDE Y N
covers al I employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Polly p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Ink need not he completed tithe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.) -
Icenifythat In tdreperfoanance attar work forwhieh this permit is brand.I shall WATER HEATER WNENT/ELECE
not employ any person in any marrow so as to become subject to the Workers' PAID
Compensation Laws of Califeran. Date WATER SYSTEMITREATING Data Receipt#
C) ApplicaNOTICE
NEW RESIDENTIAL PLMIL S FT.
0 z NOTICE TO APPLICANT:If,after making this Certificme of Exemptnioa�nr,you should Q TOTAL:
In become subject to the Workers Compensation provisions of the Labor V'you must
�n 7 forthwith comply with such provisions or this permit shall be,deemed revoked, BUILDING FEE
Q
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
U O TOTAL: ELECTRIC FEE -
the work for which this permit is issued(Sec.3097,Civ.O)
Lenders Name
U.0 r- Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W 1 certify that 1 have read this application and state that the above infomterion is MECHANICAL FEE
Qr correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,andhereby authorize represenlatives ofthis city to enterupon the
CONSTRUCTION TAX
(, above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We) nt save,In ify and keep harmless the City an a anatt against
Ilebllhlas,j dg encs,costs den ensea which may lnaoy way accrue egainstseid City AIR HANDLING UNIT(TO 10,000 CPM)
in conseyu ce f the gran ng of is permit I ft ��
/IVI AIR HANDLING UNIT(OVER IO,WOCFM)
S amre If ppiamicon Data EXHAUST HOOD OVIDUCT) PAID
HA2
HEATING UNIT(TO 100,000 BTU) Dam Receipt It
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)] VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
' ISSUANCE DATE
Will the applicantorfuturebailiingwarunt use equipmentordeviesswhich emit BOILER-COMP(3HP OR IOQ000 BTU)
limommus air commitments as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Q
I have read the hazardous materials requirements under Chapter 6.95 of the If A I D
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a annex.that it is my msponsibility to not the _
occupant of Ne requirements which must be met prior to issuace nof a Certificate of2 10P
Occupancy,
Owner of authorized agent Date TOTAL: I is Miry
OFFICE
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