25088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UILDING—ELEC1 A' PERMITNO C /}�[
APPLICATION/PERMIT PLUMBING-MECHANICAL 5 O V H
BUILDING DIVISION BUILDING PROJECT I DENTIFICA1ION'
BUILDING ADDRESS: SANI'1'ARYNO. APPLICA'IIONSUBMITIALDA'IE
21064- MARC 40URT UNIT# LOT. 2'S-�3
OWNERS NAME: YIIONE: CONTRACTOR NAMIi: LIC NO:
f1Nl it. NOW 255-9/0 �, VAU ; I6w'l'D00 irk 3 N2 CONIROL#
ARCHIIECDENGINEER: LIC NO: ADDRESS:
0 4 S'itral a-SuOn vale kd, S� CA El:ONTACI': PHONE: DU 17 ECI PERMIT INFO
Odd p�J �,/ QTY. ELECTRIC PERMIT FEE
4 12F?-6 118 PERMIT ISSUANCE BLDG ELECT PLUMB MECII
Id ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENT[AL P JOB DESCRIPTION
pw.Z Ihereby affinnthatlamlicensed uncierprovisionsofChapmr9(comYencingwith PANELS REo41e 5 /� WINDOWS
m00 Section 7W0)ol'Division 30flfc Business and Professions Cede.imdm license is in E
UW full force and effect.
FZW License Class Lice UPTO200AMPS
re<y Date Contractor 201-]"AMPS
Z O,z ARCHITELTS DECLARATION OVER IOW AMPS SQ.FI'.FLOOR AREA $/sQ.la.
O Z_O I understand my plans shall M used as public records.
SIGNS ELECTRICAL
<Y�j Licensed Podrs,ional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIDMISC.
xC W U 1 hereby affirm that 1 am exempt from the Contractor's License Law For the
V3o-vE—i following mason,(Section 903 L5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a proud in construct,alter,improve,demolish,or repair any strucwre
=WTD prior to its issuance,also requires the applicant for such penned rilcasignedsmacrom, POWER DEVICES
,=<O that he is licensed pirsuan to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
v.ao� 9(rnmmencing with Sedien]IX0)ofDivision3eOhe Business and Rvfesirns Code) � U
,M, or that he is exempt therefrom and the basis far the alleged exemption.Any violation of OUTLETS-SITCHES-
W
f—ZQ Semina7031.5byany applicant fora permit subjects the applicant so s civil penahyrf FIXTURES
S S< ma more than five hundred dollars($500).
6'3 ❑ laswneroftheproixny,ormor
yemployecswithwagesastheirsolecn,creatlon, NT:W RESIDENTIAL ELECTR SQ,Ff. STORIES TYPECONSTRUCTION
=e
will Jo the work.and the strucmm is not intended or offered for We(Sm.7014,Business / wo (•yr'I^�D
and Professions Cale:The Contractor's License Law docs net apply m an owner of wJ-V 1.
propcny who builds or improves thereon,and who does such work himulfor through his
candoyms,providel that such lmpremu
veenam not imendedor oReredfursale.IL GROUP RFS.UNI IS
however,the building rf improvement is sold within one yearercomFletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
q0 QTY. PLUMBING PERMIT FEE FLOODZONF, NPN
P Las r project
(See 7W4,mexduss..it Professions
with licensed contm.o)m
mswa the deesnot(Sec.oano acrocss soil Professions ldsCede)The Contractor's
who
ho contracts
ontrawdfor not appjects oh acoctpmpenywhosedpuouant brathereon.end PERMITISSUANCE
whatnse Low.for such projccm with ecrnlrucnn(s)licensed pursuant mthe Commctor's
License Law. / A.1JLR fl DRANJ&/V,�NW-W 'FEN FEE SUMMARY
❑ 1 am exempt under See .D&P C for this masontl CK NPPRaT1im.D VI F. t OUTSIDE FEES
Owner Date DIEM SANITARY VN
'FLOOR 11 , ' 1 RECEIP`#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ,I hereby affirm that l have a cenificateofconunrao selBimure,or a embificam of FIXTL PER TRAP _ RECEIPTp
Workers'Compensation Insurance or a cenified copy thercof(Sec.3800,Lab C.)which PARK FEE V N
covers all employees under this permit GAS-EV. F- RHCEIPT#
Policy N k, BUILDING DIVISION FEES
Company G -EA.SYSTEM-OVER 4(EA) PLANCHECK FEELo
❑ Cenifielm yisherehyfumisMd.
❑ Cenifed copy is riled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thi.useclkmm:cJ not becempleted ifthe permit is recruit hundred dollars($100) SEWER-SANITARY-STORM G.20(1 ENERGY FEE
or lens.)
I certify that in the performance of the work for which this pemtit is issued,Ishall WATER HEATER WIVENIDELECfR
not employ any ,an in any manner so as to become subject to the WorkersPAID
Compensation laws of California. Dae WATIER SYSTEM/fRF.ATING Date Receipt#
O Apphcem
NOTICE TO APPLICANT:If.after making this Cenificn¢of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y become subject to the Worker's Commorrion provisions of the Labor Code,you must 0
I'- ) forthwith comply with such previsions or this Permit shall be deemed revoked. BUILDING FEE
a >
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby uffirm that there is a construction lending agency for the performance of
U O the work for whichthis pemtit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC IEEE
tender's Name
L,
F tender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have mail this application and state that the above information is MECHANICAL FEE correct. I agree to comply with all city and county ordinances and state laws misting to PERMIT ISSUANCIE
I--' building construction.and hereby authodu repreven ovesofthis city to enter upon the CONSTRUCTION TAX
U Z above-mcmioned Property fm'msprbou purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep handless the City of Cupertino against
liabilities,judgmentx o+m mJ expects t bh mayminy way amoriciptinstSaid City AIR HANDLING UNIT(TO 10,000 CFM)
in cons 4ucncc of gmming oft ' n. 4/ /��
D AIR HANDLING UNIT(OVER I0,000 CFM)
Signature of pPlicanUCommu r V If Duc EXI IAUSTHOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE
I MAT ING UNI T(10 I00.00I BTU) Date Receipt#
Wil l the applitem or future building use upam smsre or handle hasnrdme,materm HEATING UNI T(OVER 100.000 BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Cask,Section 25532fa)] y VENTILATION FAN(SINGLE RPSID)
❑Yes )(No
ISSUANCE,DATE
Will the uPPlicanmrfuture huildinBswcupan ouequipmcn rtordevittswhichemit BOILER-COMP CHP OR 100.009 BTU)
hnaardous air crnlaminrms as defined by the Bay Area Air Quality Management BOILER-COME(OV ER 100,00(i BTU)
District
t l fJ
is rict' 11 Yea N No NEW RESIDENTIAL MECH. SQ.FT.
1 have mod the hrardous materials requirements under Chapter 6.95 of the 1#14?
California Health&Safcty Code,Sections 25505.25533 and 25534. 1 understand that ! �c
if the building dres not currently have a tenant.that it is my responsibility to notify the
occupant of the mquiumcros which must be met prior to issuance of a Cenificate of (q.
Occupancy.
Its
Owner or amhoriscJ agent Date TOTAL: ISSUED BY: ` r