25160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU ILOIGN ELECTRICAL PERM(!Na 25160
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJEC'FIDENI'IFICA'I'ION
BUILDING ADDRESS: „^'! SANITARY NO. APPLICATION SUBMITTAL DATE
UNITk I,OTq
OW NAME: PHONE` CO OR' A E: LIC NO
//44 IC NOt 7 NIC CONTROL p
RC ECL'/F[J NEER: LIC U: A ) 5S9s. O - -k--a6 // El
CONTACT: PHON U / 5 BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECU
PERMIT ISSUANCE ED ❑ ❑
L he%Ia DCONTRACfOR'S DECLARATION APPLIANCPS-RFSIDFNI'IAL )Og pEg ry
pCZ IhcrcbY off I'ENSEDiCONTR CONTRACTORS
ieDECL RATIfNaommcncing with
r00 Section 7000)of v ion 3 of the Business and PmfesstonsC ,,pnm licenseisin PANELS
,WuE full mo-sed effc 4,-10 -2
F Z y) License Class Lic,p UP TO 2M AMPS
as6a
Lac
Gonane. 201-1000 AMPS
D'n SQ,IT.FLOOR AREA E/SQ.ET.
JONZ ANCHITECTS DECLARATION OVER I"AMPS
f unders and plans shall he used ubf.orrords.
r ooh_. ♦ SIGNS ELECTRICAL
ed 11 fa pkv :f A� ,/ lK
Kd'6 ryN B. eO2C TI SPECIAL CIRCUIT/MISC.
0X0 1 a affirm that I T empa from 0e o ave 0 Li cru vw for tM1e
Witt LL y (ollowin reason.(Section] 1.3.Business and P fie ions C :Any city m county I'IiMP.METE
OR POLE INST.
C��j whkh rcyuircs n permit m onstmcL alter,improv trom h,or,rtpair any sWeture
}F prior to itaissuance,also vires the applicant for such permit file a signed statement POWER DEVICILS
E3R5 0 that he is licensed pursuant to the Provisions ofthe Contractor's License Law(Chapter SWIMMING POOL ELECTRIC la.`y Q pt g(commencing with Section]0001 of Division3of the Business end Professions Coda VAIJ�if(>N
w=y unhat he is ciomi therefntmand the basisfonhenllegedeaemptlon.Any violation of L,(�
F•ZQ Section 703 L5 by any applicant for a permirsubjects the applicanuoacivilpenelty of OUTLETS-SWITCHCS-FI%TURES
$ na more than five hundred unit...(S500).
❑ NEW RESIDENTIALELECIR —SQ.FT.
1'F`p ❑ Lasowncrmfthe prnpenY.ormyemployeeswitM1 wegcssstheirsoecompensafon, STORIES TYPE CONSTRUCTION
y3°J° will do the work,and the structure is not mendedoroffemd for sale(Sec.7044,Business
and Professions Cale:The Contractors License law does not apply in an owner of
propuny who bei Ids or improves thereon,and who does such work hitnselfor through his
ownemployees,pmvidedthatsuchimprnvementsamnmintendedoroffeudforsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yearofcumpletion,theuwmer- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sated. QTY. PLUMBING PERMIT FEE FLOOD ZONE nPN
[3I,uownemfnc�pmpeny.am exclusively amtracling wills licensed ronvacmrsm
onama the project(Sec.7044.Business and Professions CNet)The Contractor's
License lawdoes not apply to an nwnerofpropeny whobuildsur impresustbereon,and PERMIT ISSUANCE
whorontmctsmesuchprojects with a commetor(s)licensed pursuant untie Contractor's ALTTiR-GRAIN&VPNT-WATER F.A
Llccme law. ( ) FEESUMMARY
❑ 1 am exempt under Sec. .B&P C for this reamn fluBACK FLOW PROTECT.DEVICE TSI E rI S
CT
SANITARY Y N
Owner Data DRAINS-FLOOR.ROOF,AREA.COND. RLCEHg0
'TION SCHOOL TAX Y
WORKMAN COMPENSA HON DECLARA
�❑ IhcrebYaffirm Om I have a cerdfcate ofconum to sd6insum,or a certificate of FIXTURES,PER THAT RI!CEIPI'pN
Workcm Conienmlionlnsu mceo cenifledcopY ereof(Sec.3800.Lab CJwhich PARK FEE Y N
RIiCEIPI'p
coven all<mployee's under this permit. GAS-EA.SYSTIiM-1 .. O
Policy p L. BUILDING UI V ISION FRES
Company aGAS-EA.SYSTEM-O 4 EA, P CHECK Fr.3
furn
❑ Candied copy is hereby ished.
❑ Certified copy is filed with the city inspection division. GREASMI "S7RL T A INGI E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP DATE OILS FEB
COMPENSATION INSURANCE
(This station need not be completed ifthe permit is furore hundred dollars SEWER-SANT V-STORMEA.200M ER I:
or less.)
I
cattily that in the performance of the work for which this permit is issued.i shall WATER HEATER W/VENI/ELECTR
nn employ any parson in any manner ,to, n become subject t0 the Woders' PAID
Compenedion Lawsof California. Dunes WATER SYSTEM/I'REATING Date Receipt#
0 Z Applicant
Z NOTICE TO APPLICANT:IL after making this Certificate NEW RESIDENTIAL PLMB. 5 of Exemption,you should Q Fr. "OTAh:
F' y become subject to the Worker's Compensation provisions of the Latin Cede.you must
forthwith comply with such provisions o,,his permit shall be deemed revoked. BUILDING FEE
HJ Q CONSTRUCTION LENDING AGENCY SEISMIC FITE
z I bercbyuffrnt shat then is a eansvuelion lending agency funic parmancoce of TOTAh; ELECTRIC FEE
U O he work for which this penin is issued(Sec.309].Civ.CJ
I<Ner s Name PLUMBING MI;
r1' F Lendre.Address QTY. MECHANICAL PERMIT FEE
U I eerily the,1 have read this.pplication and swm that the above information is MECIIANICAI.FEE
>. 4 correct. I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
buildiogeonav sea ,and hereby aulhnrise representatives ofthis city to emteruponthe CONSTRUCTION TAX
U shave-menti ed pmpeny for inspection purposes. ALITR OR ADD TO MECIL
ir.
(We) gree m save,indemni' and keep harmless the City of Cupenimo against
liabilitic udgmenb.costs awhichmayin eny wayaccme againstmid City AIR HANDLING UNIT('1'O IO.OW CFM)
in cucrou of EcRom nfthispcmtit.
AIR DANDLING UNIT(OVER IO,gXI CFM)
.armature of Ap c o or arc EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERI 'DISCLOSURE HEATING ON]-[(TO 100,000 BTU) Date Receipt#
Will 11 upplicvm or future building swcupvnt snsrt or handle harardous material HEATING UNI'1'(OVER I(O,gO BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safely
Code,Sermon 25532(a)] VENTILATION FAN(SINGLE RESID)
❑Yo ❑No
BOILER-COMP CHP OR 11(1,000 BTU) ISSUANCE DATE
Wus air auddraimans as building occupanttau equipmentQualit �whiManagement
hazardous air mmaminunts sea defined by the Buy Area Air Quality Manugemem gO1LER-COMP(OVER IW,g0 Bt V7
Districts P p D
❑Yea ❑No NEW RESIDENTIAL.MECH. SQ.FT. �'G
1 ha twA the hmarunus mmttials reyuimnen6 under Chapter 695 of the J' Q
Califo Health&gafny Cede.Sections 25505.25533 and 25534.l understand that — �Q
ifihe it imgdocsaod yhvveatenanl.thatitismyresponsibilitytonotifythe .99 V19
t of the rept Is which muse N ten prior te issuance of v Ccnificate of w
an . \p� /,aa���
coalition at TOTAL: ISSUED BY:
V1�')tU
OFHUL
1