25754 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRI A PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL _ /1 r p
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L 5 5 4
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
1 UNIT# LOT# 1(— ' Z�3
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: f
A BA4 U-I @r T/-O/O O G S O m r- XIS(. NIC CONTROL#
RCH11'ECULNG EER: LIC NO: ADDRESS: El
ost l
coNTwcr: PHONE: ELECT
PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
1. 0 365-/66b PERMIT ISSUANCE 0 1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ISI
azz I hereby affma thatl am licensed underprovishersofChapter9(commenciagwith JOB DESCRIPTION
[x100 Section]0UU)of Division 3 of the Business and Professions Code,and my license is in PANELS
FC full force and effect. \^_
pQ„Z LicensefJzssLia# 61338 UP T0200 AMPS G (,'•l Lr �e y�
Fly Dale ��// Contractor LHON MB%O�n y 201-1000 AMPS
Z8y4 ARCHITECT'S DECLARATION OVER EXIOAMPS. Q R $f Q.FT.
O Z•F.O 1 understand my plans shall be used as public records.
P K p.] SIGNS ELECTRICAL Licensed Professional
WF �-� Y l
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt from the Contractor's License Law for the
�+3 w following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
which requires a permit m construct,alter,improve,demolish,or repair any structure
42 prior m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
1y [�Ljcos
q0 that he is licensed pursuant to the provisions ofthe Councedur's License Law(Chapter
4Xp� 9(com orming with Section]000)of Division 3 ofthe Business and ProRssians Code) SWIMMING POOL ELECTRIC VALUATIONor
ul m
Section
7031. hymympt therefrom and the hasiefarthermflaalleged
,Plica exemption.Any violation of OUTLETS-SWITCHES-FIXTURES /q �// 1
Seetion]tax (i any applicant bar a subjects the npplicangoacivil penalty of C/ l/
La t more than Mef hundred dollars($500). NEW RESIDENTIAL,ELECTft S .PI'.
[gy[x1 m n❑ 1,asawnerofthepropcny,ormyemployeeswithwagcsastheirsolecompcmation, Q STORIES TYPE CONSTRUCTION
p, will do the work,and thestrurtme isnor intendedoroffened foram,(See.]044,Bminess
and Professions Cade:The Cmuacter's License Law does not apply to an owner of
property whobuildsorimprovesthereon,andwhodmesuchwork himselforthrough his
ownemployces,provided thatsuch improvementsare not intendedorofferedforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearof completion,the owner.
builder will have the burden af n that he did not build or improve for TOTAL:
proving P purpose of
me.).
❑ I,asowner of the property,am exmaaroelynanaaetmg with licensed contmcmrsto QTY, PLUMDING PERMIT FEE Fl.00D zone APN
construct the project(Sec.9044,Business and Professions Code:)The Contractor's
License Lawdoesnot apply toanownerofproperty,whobuildsorimproves thereon,and PERMIT ISSUANCE
whocontracts forsuchprojects withacaatnectm(s)licensed pursuant tothe Commetor'e ALTER PEE SUMMARY
License Law. (EA)
❑ I am exempt under Sec. ,B&P C for this reason SIDE FP,ES
BACK FLOW PROTECT.DEVICE SANITARY YN
Owner DateDRAINS-FLOOR,ROOF,AREA,COND.. RECEIPTq
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm that l have a certificate ofcunsent to self-insme,or a certificam of FIXTURES-PER TRAP RECEIPF#
Workers'Compensation Insurance or acertifim copy thereof(Sco.3800,Lab C.)which PARK FEE Y N_
P v cy All emplo�ep'sder�jytscrnit. RECEIPT#
.SS.l 77 ll'`ff GAS-EA.SYSTEM-I INC.40UTLETS BUILDING DIVISION FEES
Com Celt d OL<_ mu GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Otis section mvd.mbe completed ifthepernot is far ane hundreddo11ms($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les")
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENTIELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensation Laws of Califomia. DateWATER SYSTEM/TREATING Date Receipt#
Z Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
p] become subject to the Workers Compensation provisions of the Labor Code,you must
Fa' ,forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE 7e C d
l, CONSTRUCTION LENDING AGENCY SEISMIC FEE I
z I hereby offum that there is a construction lending agency far the performance of TOTAL: ELECTRIC FEE.
U 0 the work for which this permit is issued(Sec.3097,Civ.CJ
L1J r.l Leader's Num.
Q U Lender's Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and state that the above information is
acorrect.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICALFEE
�-" J building conintledomand herebyautharize representatives ofthis city meawc.pon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
.^� (We)agree to save,Indemnify and keep harmless lie City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
nsequcace of"tgranting o his permit.
C I � AIR HANDLING UNIT(OVER I0,000 CFM)
SiEndomof ApfeanUCo mann Dero EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle haxmdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00)BTU) TOTAL:
Code,Section 25532(a)]
11 Yea El No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will thea licanmrfutum building equipmen BOILER-COMP(3HP OR IW,m)BTU)
pp g by the Bay rouality Mange ant
ha>ardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? 'PAID
Yea 13 No NEW RESIDENTIAL MECH. SQ.IT.
I have mad the hazardous materials requirements under Chapter 6.95 of the utll�� 12
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that w Im
if the building does not currently have a tenant,for it is my responsibility to ratify the
occupant of the requirements which must be met prior to issuance of a Certificate of �I'I.Y WM V Uf"Ct'1 I IIVV
Occupancy.
Owner ar authorized agent Date TOTAL: ISSUED BY: ININ, ALL /
OFFICE
r