25476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELM IRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25476
BUILDING PROJECT IDENTIFICATION
aBUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE 3 Z 1 I 1r�5�',s1 1" 1 TN-e_ LOT# q 3
OERS NAME: PHONE: CI'OR'SNAMR .LIC NO:
R
N/C CONTROL#
ITE 1 BER: LIC NO; AP.0RESS: ❑
CONTACT: PHONE: ..
QTY. ELECTRIC PERMIT FEE BUE.DING PERMIT INFO
D ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ivp1WZ Ihcreby s Nal l am licensed underprovisionsof Chapter9(commencingwith
FWO Sectiorcee")rdDv/tid'ing 33�Oyt Ne Business and
/Professions Cods,and my license is in PANELS K Q' •,J^r_a-A-�,
Fz Liconu Clnsdd effort�Lic.# aftl3-51 UPT02W AMPS fi 1 flava
vs?y pare Can tmnor�Qsq� 201-Ia10 AMPS S FT.FLOOR AREA 3/SQ.FT.
ZOvZ ARCHITECTS DECI.AR i N OVER IMAMPS
Q
O Z-G 1 undcmand my plans shall he used as public eccor s.
F,x..44 Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISG
x0 W F I hereby affirm that I am exempt Tran the Cotnractars Liceme law for the
W 3 u-rn following reason.(Section 703 1.3.Business and Profession Cade:My city or county TEMP.METER OR POLE INST.
i which requires n permit m mnemic,,ober,improve,demolish,or repair any dr ucturt
C�Q� prior to its issuance,also requires the applicant far well Permit m rile a uprol statement POWER DEVICES
W 5 p Oz that he is licemed pumuamt to the provisions of the Correctors License Low(Chapter
66�LL 9(commencing with Section 7000)af Division 3 of Ne Businessland Prefessions Cade) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exempuhemfremand the breis forthe Nleged exemption.Any violation of Olfl'f.EfS-SWITCHES-FIXTURES e71�
FZ�' Scnion 70J LS by any applicant fon permit subject the applicanuoecivil penalty of
Q oat more than five hundred dollass($50). NEW RESIDENTIAI.ELECRt _SQ.FT. STORIES —s TYPE CONSTRUCTION
€O
❑ Lnownk,md tproperly.ormyemployecswithwegesaatheiraol.compensation,
y3- will do fission and the strvaureimormeicense Law ffered
apply go 1�1an Bisons
and Property
wh ons Cade:The Contractors License law does not apply lf an owner of
such
ownmylhecs, ovidi thatswhimpmvdenmd sotinwork oroffforthr We.Is OCC.GROUP RIS.UNITS
however,
the
ebuilding
u lding cedthat suchimprovememu arc not ouggro cdaroff un,for We.If,
howeer wiH have
burimprovementismid hathe did
build or improve for
thcowner- TOTAL:
builder will have the burden of proving Net he did not build or improve fa puryose of
sale.).
❑ T,asownerofthepropeny.umexclusivelycontmctingwiNiiamedcontmnomto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
caruwm the project(Sce.7054,Business and Professions CW.:)The Common's
License Law domnotapply tans ownerofpropeny wholedidsor improves therwn.and PERMIT ISSUANCE
whocommormsfarsuch projects with aconvuctoris)licensed punuannothe Contractors ALTER-pRAIN&VENT-WATER(FA)
Licrnm Law. FEE SUMMARY
❑ I esn exempt under Sec. ,B&P C for thin reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
Owner Date SANITARY RECEIPT# N
WORKMANCOMPENSATIONDBCT RATION DRAINS-FLOOR,BOOP,AREA,COND. SCHOOL TAX Y N
❑ Ihereby off.that i have a certificate ofcansem to self-insure.or a certificate of AAJ RECEIPT#
Workem'Compenaation lnsumnce or a codified copy thereof(Sey.3801 Lab C.)which sR PARK FEE Y N
covers a 11 employee's un der this permit. _ AS- A,S)N -11�4 U F,Ts. RECEIPTp
Policy Is BUILDPIG DIVISION FEES
CompanyortinL 1,1}>cys-6yCsl t G " ii �.,5 S R4 PLANCHECK FEE
❑ Cem e p ubI, y umsahed.
[I Candied copy is filed with the city inspection division. GRF DSTRL E GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ONEASE'BAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars I$ 10) SEWER-SANITARY-STORM EA.20FT. ENERGYME
or less.)
I certify that in the pefi munceofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELELTR
not employ any pecten in my manner sec our to becotm subject to the Workers' PAID
Cion,nsutiom Lwsof Califumis, Data WATER SYSTEM/17RHATING Date Receipt#
Q Z Applirmi
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rn become subject o the Workers Compensation provisions of the Labra Code.you must
forthwith comply with such provisions or this permit shall be doomed revoked. BUILDING FEE
per, z CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there is a const union lending agency for the porrenmunce of
L) O the work for which this pernit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
U. ,s Lender's Name -
0 U Lenders Address QTY. ' MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and state that the above informmion is
cornett l agree to comply with all city end county oninaness and shite laws misting to PERMIT ISSUANCE, MECHANICAL FEE
to building construction,and hereby authmnae representatives of this city In enter own the
L) 7 shove-mentioned nsppury
property for inspection grimaces. ALTER OR ADD TO MSCI L CONSTRUCTIONTAX
F7 (We)agree m save,indemnify and keep houni the City of Cupertino against
liabilities,judgments.ensu and expenses which may in any way accrue against said City AIR HANDLING ON"(TO I 0,000 CFM)
i omequence ofting of this permit. m/ AIR HANDLING UNIT(OVER 10.0 CPM)
tSignal..of Apphrom/Contrsoun Date EXHAUST HOOD(W/DUC ,
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant or future building occupant store or handle haurdous materiel HEATING UNIT(OVER I W,Ooo BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,add Ne Health and Safety
Code,Section 25532(.)7
❑Y. IJ No ENVTILATION FAN(SINGLE RESID)
Will the applicant in futurebuildingoecupent use equipmemordeviceswhich audit
BOILER-COMP OliP OR 100,000 BTU) ISSUANCE DA
TS
headrdom air contamirnnts as defined by the Bay Arta Air Quality Management BORER-COMP(OVER 100,000 BTU)
DisR n7
❑Yes ❑No NEW RESIDENTIAL MECIi. SQ.FT.
1 have read the hamrdous materials requirements under Chapter 6.93 of the PAID
Califnmia Health&Safety Code,Sections 25505.75533 and 25534.I understand that oy
if the building does n0y have a anent,Nat it is my responsibility m notify the
pans of the uirtmen which must be at Food..bra ancjspf C< ifcete of
P y
Owner or authonred agent Da TOTAL: IWr