25502 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPER'PINO
Ji'C-KLKCTRICAI. PERMITNO.
APPLICATION/PERMIT PG-MFICHANJFIC 25502
BUILDING DIVISION BUILDING 1'R(JJF,CT IDRN'TIFJCATIQN
BUILDING ADDRESS: f�\/� SANITARY NO. APPLICATION SUBMITTAL DATE
lOLOZ • 'J�/�Au� YR UNIT LOT
OWNERS ME: PHONE: .! CO A C NAyJE: s LIC140 1 NU: Z�ZJJ� Fi
UNN S "4V4 iL.L� ) / / ✓-- r� N/C CON'1'RUI.p
RCIIIIPCT/ENGINEER: LIC NO: AD S. I�T� ` GF/
� ni er
CONTACT: PHONE: QT'Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
eLD(: E SCI' PI UMB MECII
PLRMI'IISSUANCE
LICENSED CONTRACTOR'S DECLARATION r. APPLIANCES-RESIDENTIAL
CCz I hereby afire that l am licensed under previsionsofCTaper9(cotmncmciagwith JOB DESCRIPTION /
0 Section 7000)of Division 3of the Businessland Pefessioms Code,and my license is is ell- PANELS M�
yvw1 fall fare.x Class effect. • '�V Vv`
U U UP TO 2M AMPS
ooDate Clan Cut
y 6 y Dec Contractor 301-1000 AMPS SQ.FT.FLOG AREA $/SQ.ET.
F-yz ARCHITECTS DECLARATION OVER 1000 AMPS
z0`o,— 1 undentandmy plane shall be acedus publicrecords.
O!—
)yM SIGNS ELECfRICAI. Y
Licensed Professional
�Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O yU I hereby.ffiw that I um exempt fn+m the Cnntmcmr's License Law far the 1
W'3LLbe following reason,(Seven.7031.5.Business tied Prnfemims Cade:Any city mr county TEMP.METER OR VOLE INS'1'. 1Q
F'a 0 which tequves v permit to conswet,alter,improve,demolish m repair any nmctum 7 v
CWQ� prior to its ismance,almrequires the applicamtfor such permit to file a signed statement POWER DEVICES ��y OIm
that he is licensed pursuant to the provisions lithe Contractor's License Law
p _ll
d C.p4 9F, ntmencing with Section 0000).!Division Jaffee Bs,inessand Professions Code) SWIMMING POOL ELECTRIC ���111Q VALUATION
p_e, nrNatheisexempttherefromandthehasieforlhedlegedexemption.Anyvirreemof LETS-SWITCHES-FI%TURES 27
z 4 Section]031.5 by any applicant for a Permit subjects the applicant to a civil penalty of J
5xp not more than five hundred dollars($500).mstructureNEW RESIDENTIAL ELECIR —SQ.FT. STORIES PEeCONSTRUCTION
�f^m [3I.asowncrnf Neproperty,ormyemy[
lli swithwagesastheirmpe
l[comnsation, - Y v
will Jhework.and the structure is not intended enflbred term44
termite 90 ,Business
and Professions Code:The Contractors License Law,does not apply to an owner of
property who builds m improves thereon,end who doessuch work himself or through his T
employees,provided that such imprnvementsare not ionendedoroffered lbrmle.If, p ■ LS.UNITS
however,the building or impravemene is sold within meyear ofeompletion,thrower- (� INA 11 p Y
builder will have the burden of proving thus he did not build car improve for purpose of 1 Lera 'L!
mild. QTYPLUMBING PERMIT FE l L APNJ
❑ [,as owner nitre pmpeny,nmexdusivdy, contracting with llicensedconvmm .
contractors —J`
Lmvwct taro project(sa.?004,Business arta Professions C<de:7 The Convacood }E
icence Lawdoes not apply manownerofpepcny who buildsor impmvesthcrcon,and PERMIT ISSUANCE
whoconreacts forsuch projects withacontmetons)licensed pursuant eche Convectors
License Law. ALTER DRAIN ffi VENT-WATER(EA FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE ES
tPARKFFE
TARY Y N
Uwrter Date DRAINS-FLOOR,ROOF,AR G.COND. RIiCEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ibunchy affirm that l have a cenifieraccecommau.self-insure,are certificate of FIXTURES-PER TRAP ./ RECEIPT»
\Vnrkerv'CompenseYnnlmumnce oravenifcJ ntpy thercof(Sec.JN00,Lub C.l which YN
coven all �d�i�['ptit. D�/T»7 //O GAS-EA.SYSTEM-I INC.4 OUTLETS -� RIiCISION
poli 7J Lam[/ BUILDING DIVISION FIiI3
p GAS-F.A.SYSTEM-OVER 41 PLANCRECK FER
ed copy is filed with copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CER'rIFICATEOFEXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This Serino need
of be completed ifthe permit is formER
ne hundred dollars(E100) 5 -S)I1'1'ARY-STORM EA.200FT, �' ENERGY FEE Iv
or less.c
m
I unify that in the performance of the work for which this permit is issuN,ishall :It HEATER W/VENr/ELECITt //
nemptily any come a+beme
n 1a tiny manner so as comb.m the Workesi PAID
Compensation Lawsof Califoeia. Date WA'I17 SYSTEM/BEATING Date Receipt If
O Z Applicant
Z0 NOT'ICE TO APPLICANT:If.after making this CeniGcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Fr. TOTAL:
� �. Femme subject n the Workers Compensation provisions of the Labor Code,you must BUILDING FEE
> forthwith comply with such povi,ino or this permit shall be deemed resolved.
aFCONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z I hereby affirm that here is a construction lending agency for the performantt of
U O ELECTRIC FEE
the work far which this l+eentit is issued(Sec.3047.Cls.CJ T
Lender's Name PLUMBING FEE
Lenders Address QTY, MECHANICAL PERMIT FEE
U 1 lenity that I have read this application tied state that the above intent ons �e MECHANICAL FEE �e
W amect. I agree to comply with all city and county ordinances and Stam laws relating to PERMIT ISSUANCE
M1uildi traction,and herebyee isc represenmtives oftbi,city[literalism the CONST RUCTION'1'AX
UZ litho -meet mealpeopcn ' s Ginn pulposus. AUTER OR ADD TO MECI I.
(We) gra 1.s J fy and lva Icss a City of Cupcnino against
1 far lities.'idgmen .,am,w in mayy way aececagainst said City AIR HANDLING UNIT(TO 10,000 CFM)
he nI flhis it.
— � AIR HANDLING UNIT(OVER IO.q%1 CPM)
IQ
SiR arc of Applie nt/Cnnv mr Dee E%HAUBT HOOD(W/DUCT') PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Igl,gNl BTU) Date Excerpt»
Will the applicant or lotus,building occupant store or handle haardour matenal HEATING UNIT(OVER 100.1100 BTU) TOTAL:
tie Jcfined by the Cupertino Municipal Code,Chapter 9.12,and the Both sod Safety
Code,section 25532(a)? VENTILATION FAN(SINGLE REBID)
t ❑Yea ❑Nn ISSUANCE DATE
Willtheapplicantorfmumbuildingmcupuntuseequipecntordevi[eswhichemit BOIL[R-COMP(3HPOR 100,000 BTU)
�ilaose s all contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
Dioner? P A 9 D
�
❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FT.
I have read the resurrects materials re,meareents under Chapter 695 of the �0 p 1993o
C.Iifnmia Health&Safety Code,Sections 25505.25533 and 25534. lundersmndthat �1 �
if the building does not currently have a tenant,that it is my re,or sibility to notify the GOT
btl v
occupant of the requirements which must fe met prior to isxaamce are CeniGcateof
C
I I Y l
Occupancy. /Y
Owner or.ummired.,car Date TOTA ' IS9UEDB