25458APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
APPLICATION/PERMIT
BUILDIN17 ELECTRICAL,
PLUMBING - MECHANICAL
PERMIT NO.
25458
BUILDING DIVISION
BUILDING PROJECT IDENTIFICA9'IOry
BUILDING ADDRESS
SANITARY NO,
APPLLICA'DON SUBMITTAL DATE
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CONTRACI'ORSNA
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NO:
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ARC IHECT/ENGINEER: LIC NC- ADDRESS:
CONTACT: PHONE:
QTY.
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MF,CH
PERMIT ISSUANCE
❑ ❑
LICENSED CONTRAC'TOR'S DECLARATION
APPLIANCE7S-RESID17M'I AI.
JOB DESCRI Vl'ION
I hereby affirms that I an licensed underpruvisionsof Chaptnr9(commencingwith
Section of Division J of the Business and Professions Code. and my licenu is in
fail rnrcn and lass effect.
PANELS
License Class Llok
UPT02W AMPS
Dam Contactor
201 - 1004) AMPS
SQ. PT. FLOOR AREA
$/SQ. IT.
ARCHITIl DECLARATION
OVER 1000 AMPS
1 understand ney plans shall be used as public remands.
SIGNS ELECTRICAL
'
Lice sed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
�—
I hereby affirm that I sm exempt from the Complctors License Law for Ne
followiniinvnn.(Ser (Serums 7031.5. Business and Professions Cade: Any city or county
TEMP. METER OR POLE INST.
wh lch requires a permit to construct, alter, Improve, demnl ish, or repair any structure
primmitsissuance.also image, the applicant fnrsuch pemtimo file asignedmememem
POWER DEVICES
that he is licensed pursuant to the Provisions of the Contractor's License Law (Chapter-
_ VACUAl ON
9(commencing with Section 7000) of Division 3 of me Business and Professions Code) SWIMMING POOL ELECTRIC I n n p
or that he is exempttherefrom and the basis for the alleged exemption. Any violation of
Section7031.5 by myappliciam far apenniteubjectstheapplkpenalty car
OUTLETS -SWITCHES -FIXTURES
-ammacivil
1�-•• Ill
ore than Bvc hundreJ Jailors (SSW).
n Lasowai fo propeny,ormyemployas withwegcsas Neirsol¢ompeane4on,
NEW RESIUIlJTIAL ELECTR �rSQ`FT.y
SV
0�• f�
I �R ,.1
TYPL'CONSTRUCDON
aril othe work, and the structure is not intended or offered for side (Sm. 7044, Business
and Professions Code: The Contmctoi s License Law docs not apply to an owner or
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property who builds or improves thereon, and who this such work himselfor through his
RES. UNITS
d Nre
employees, provideat such improvementsanot interal ndedoroffeforsale. If,
however. the, building or improvement is sold within one year of completion, me owner -
builder will have the burden or proving that he did not build m improve fm purpose of
sC]
QTY.
PLUMBING PERMIT
FEE
FLOODZONE
APN
❑ Las owner ol sivelyconrnning sed
jest (Sm. 70, . Business Professions Ccslc:) The ontracnm
the project tom. o Business and Code:) The Cocoon.
icetmn
ano ywhobild and
Licenx Law does nm apply mwownerofproperty wM1obuildsorimproves mereon.end
PFAMIT ISSUANCE
who contracts for such projects with aconteactor(s) licensed pursuant to the Contractor's
ALTER - DRAIN &VEN(T-WATER PA )
FEE SUMMARY
Licenis Law.
❑ 1 am exempt under Sec. , B & P C for this rcasnn
BACK FLOW PROTECT. DEVICE
OUTSIDE: FEES
SANITARY YN
RECEIpTp
Owner —Do.—DRAINS
WORKMAN COMPF.NSA'1'[ON DECLARATION
- BOOR, ROOP,AREA, COND.
SCHOOL TAX YN
[:j Ihercby urlinn thmlhave uceni0cute of ennxnl mself-insure. orucertifcme of
FIXTURES - PER TRAP
RECI]"#
PARK FEE Y N
PT p
Workers' Compeeation lnsuremce or a certified copy thercof(See. 3900. Lab C.) which
covers all employees under this permit.RECI?I
GAS - EA. SYSTEM -1 INC.4 OUTLETS
BUILDING DIVISION FEES
policyp
Cnmpamy
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FT -H
❑ Cenified copy is hereby famished.
GRADING FEE
❑ CcnificJ copy is fled with Nc city impartial division. GREASMNDUSTRL WASTE INTERCEPTOR
CPS'rIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCh
ENERGY FER
(This section need not be completed iflhe permit is forone hundred dollars ($10)) SEWER - SANITARY - STORM P. 200ET.
or less.)
I certify that in the perbnmmce of the work for which this permit is issued, l shall WATER HEATER W/VENDELECTR
an employ any person in any m . so as to became subject to the Workers'
PAID
CarTvmambm Lnwsof Calil'omis. Date
WATER SYSTEMITRUA'1'ING
Date Reemla#
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption. you should
NEW RESIDENTIAL PLMB. SQ. PC
TOTAL:
become subject it, the Worker's Compensation provisions of the Labor Code, you must
fonM1wlth comply with such prwislons or Nle permit shall he deemed revoked.
BUILDING PEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending ugvery for the performance of
TOTAL:
ELECTRIC FEE
the walk far which,hi, permit is issued (Sec. 3097. Civ. C.)
Lender's Name
Leader's Address
QTY.
MECHANICAL PERM I
FEE
PLUMBING F171:
I certify that I have read this application end state that the above information is
MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and state laws miming to
PERMIT ISSUANCE
huilding construction, and hereby amhorino representatives of this city rt enter upon the
CONS'TRUCf10N TAX
abrve-mentioned pmpeny fm inspection puHcses.
AL'1'ERORADDTOMECI I.
'
(We) agree to save, indemnify and keep harmless the City of Cupertino against
dities,judgmenta.costs and eapenseswlf It yin an ywayaceroeagaimtsaid City
AIR HANDLING UNIT (TO 10,000 CFM)
eymaccof thegmmingofthi,pe n.
NR HANDLING UNIT (OVER IO.IX4) CFM)
PAID
Si amreaf peon ummctor Dl EXHAUST DOUG GV/DUCD
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Dam Receipt X
O AI.
Will the applicant or future building occupant store or handle hazardous material IIFATING UNIT (OVER IW,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532OU
11 yes 13 No
VENTILATION FAN (SINGLE RFSID)
ISSUANCE, BATF,
BOILER- COMP QHP OR 100,000 BTU)
Will the applicant orfuturebuildingeccupell use equipramalmdeviceswhichemit
havWoas air commitments ® defined by the Bay Aro Air Quality Management
BOILER - COMP(OVER 1W,000 BTU)
District?
❑ Yes ❑ No
NEW RESIDENTIAL NIECE. SQ. FL
P A ' D
i M
1 have read the hmmmous materims requiremcns under Chapter 695 of the
if the building docs not curremly have nt Nat it is my responsibility m notify me
a mou
California Health & Safety Code. Sections 25505, 25533 and 25534. I mMerstand thatacf(
7
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
ISSUED BY:tH(II�V
Owner or amhosial agent Data TOTAL:
OFFICE