25554 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILII:N.-ELECfRICA L PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25554
BUILDING DIVISION BW LDING PROJECT'IDENT'IF'ICATION
BGILDING
ADDRESS:
SANITARY NO. I APPLICATION SUBMITTAL DA'T
elf" UNIT# LOT# [w I 1
OWNP SN ME: ONE: � CONT CfOR'SN LIC NO: 1 111...
N/C CONTROL#
RCHfrI C1'/ENGINL L: LIC NO: ADDRESS ❑
ONTACF: PHONE:
QTY. BLECTRI( FEE BUILDING PERMIT INFO
S°l ` Ex P* Cf
••1 II'
PERMISSUANCC
LICENSED CONTRACTOR'S DECLARATION APPLIAN - DF. AL JOB DESCRIPTION
qq K.4 I hereby affirm Nat l nn licensed under provisions ofChapter9(mmmeucingwith
tr100 Section]IXl)l of Division 3 of the Business and Professions Cade,and my license is in P NE S
FYU� full toren and effect. ^^ '
Fyul License Class Lic.p 200AMPS M0PSOk sDF
y=y Date C CTS'ar 01-10N AM �V I�"�w"�W
ARCHITECTS DECLARATION SQ.Irl'.FLOOR AREA $/SQ.FT.
1 undcmmnd my plans shall be uud m public records. OVER I A
OZ—G ��1 l
Py W ' G lit is 1 I.
q��dd
Licensed 1'ml'uaionel
gys < OWNER-BUILDER DECLARATION r AL NIT/MISC.
KOs. 1 hereby affirm that I am exempt from the Comrmam's Li«nae law for the r 0�
W3OvFi following mas.a(Sretion]oJLS,Businev uM Pmfasiona Code:AnY city orcoutv
nty .MP.MITS OR PoLP.INST.
:E`y� which requires a Permit to conswct,apar,improve,demolish,or rcpuireny swcturt
priurlomixsuance,alsarequires theapplicum forsuchpennittofileasi,aad statement POWER DEVICES
QO that he is licensed pursuant to the provisions cribs Contractor's License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
440 9(cot he is exemng ptherafrn'mnd)ofthe basisian 3 ithe theed exess andmption.
Professions Code) —124
/ 01
^y or that he is exempt therefrom and the husisfmthc dlegeJ exemption.Any violation OUTLETS-SWITCHPS-FIXTURES S /
F 4 Section 7031.5 by any applicanr fora permit wbjeets the.Pplicanuo a civil penalty o tot
O t re than Ove It do'I Jnllars($500). NEW RESIDENTIAI,ELECTR S .FT.
,ae.wnemfthepmpeny,ormyemployeeswith wegesustheiraolecampensatinn, Q S'I'ORI,S TYPE CONSTRUC'T'ION
4 _ 111 ewark.and the swnureis not imendedoroffertA farsale(Sec.71144,Business
and Prole si ns Cade:The Conuacam's License Law does not apply to an owner of
properly who buildsorimprovestheraon,and whodoessuchwork Nmastforthroughhis
nemployma,provided that suchimprovcmrname not itneralmoroffered forsals.If, -OCCGRO ® S. ITS
M1 wever.the fouldingor improvement is sold within one year ofmardetion,theovvac- 0
builder will have the bunko of proving that he did not build or improve for purpose of d•�
aaaaa
fie')' APN
❑ Lmownerofthepmpeny.act exdusivelycontractinB with li«vMcontmctars to QTY, PLUMBING PERMIT Y
nsuuct the project(See.70144,Business and Professions Code:)The Commctm's PERMIT ISSUANCE
License Low dues out apply to an ownemf properly who bui Ede or improves thereon,and
who contracts fursucb pnilects withucunvuor(s)IicenseJ pursuanno[his Contractor's
ctALTER-DRAIN&VENT-WATM, (PA)
License
❑ I and exempt under Sec. ,B&P C for this reason BACK ROW PROTECT.DEVICE OUT11ITT-Erg
SANITARY YN_
Owner Dam RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
CIIhereby affirm Nmlhavee cenilicate of consenuo selLineure,oro cenificate of RECIiIPf#
Workenf Compensation Insurance me certified copy thereof(See.3e W,Lab C.)which Il%TURI'S-PER TRAP PARK FEE Y N
RECEIPT#
coven all employee's undcnhia permit. GAS-FA.SYSTEM-I INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company GAS.P.A.SYSTE M-OVER 4(EA) PLANCHECK ILF. 11100
❑ Ccnlfied copy is hereby fumi.hed.
411
❑ Cenilinl copy is flet with the city inspection division. GRFASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE /w
COMPENSATION INSURANCE
(Thissectionneed not he completed ifthe pemtit is farane hundred did...($1010) SEWER-SANITARY-STORM IA.200FT. ENERGY FEE —as#
or las.)
1«nify that in the perlonnance of the work for which thispe.mit lsisauW,lah WATER)IPATER W/VPNT/P1ECfR -13
not employ any person in any runner ao as n herons subject m the Work PAID
z Compemation Lwsaf Califumu. Date WA ERFS,S.- E¢11 G Date Receipt#
Applicant
NOTICE1'0 APPLICANP.ILaftermaku,nus Cenifcvmof Exemption,you oho Id NEW RIS'Dr jAl 1:-11'. � SQ.In. TOTAL:
F-' tn M1ec.mc auhject to the Workers Compensation provisions of the Labor Cale,you mus'
fmflo ith comply with such provisions or this permit shall be decimal mvakal. BUILDING FIM
W CONSTRUCTION LENDING AGENCY I- SEISMIC IEE
z T-AD
^a I hereby affirm that there is a construction lending agency for the performance of ELECTRIC FRE
re
UO thewurk Reshichthispermit ie ixamd(Sm.309],Civ.C.)
I2. Lenders Name PLUMBING ILF.
O U lenders Addres QTY. MECHANICAL PERMIT FEE
1 tenor,that I have read Nis ap,Ii.,i.n and nen Nat the all Infestation..is
0. comm,l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
_ building construction,and hereby a dmim representatives of this city In enter upon the CONSTRUCTION TAX
U Z .boas watiancd pnaparty for inspection purposes. ALTER OR ADD TO MSCI I.
(We).gree to aave,indemnify and keep h ess the City of Cupenino against
Win it, era sea whit ay many way same against said City AIR HANDLING UNIT TO 10,000 CFM)
as us, c ting of this
L Q• AIR I IANDLING ON IT(OVER 10,000 CPM)
Si eau of .mrector Date 7 EXHAUST HOOD WTlUCT) PAID
c HAZARDOUSMA � IALSDISCLOSURE HEATING UNIT(TO 1011,0011 BTU) Data Receipt
pplicut or future building occupant store or handle bavurdoua material HEATING UNIT(OVER IW,000 BTU) TOTAL
as defnad Ery the Cupenina Municipal Cale,Chapter 9.12,and the Denhh and Safety
Cale,Section 25532(a)] VENT RATION FAN(SINGLE RESID)
❑Yes ❑No
Will heupplicant or future builJingoccupant meequipmentordevicea whichemit
BOILER-COMP CHP OR 100,000 BTU) ISSUANCE DATE
uzmdnm air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,(g()BTU)
IevinP k51
❑Yes ❑No NEW RPSIDFNTIAI.MECI1. SQ.FT.
I have read the hassrdoas materials requirements under Chapter 695 of the DEC m 1993Califamia &Health Safety Cade,Sections 25505.25533 ad 25534. I understand that
if the huildi ng does not currently have a tenant,that it is my m.ponsibilby to notify the
Oce V rico'the requirements which must he met pd.,to issuance of a Ccnificate of CITY u
Owncror e.thadsod ager[ Dataas ISSUED BY: Ery
OFFICE