25139APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELEC'I'RICA], PFRMI,'NO. 2 5 1 3 9
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION I ...a. I— - oo„re.-..,,.r.�,1-11.1-11
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AWARCHI'IECI'/ENGINEER:
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CONTwCT: PHONE:
QTY. ELECTRIC PERMIT
FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
noel
n that l sum licensed under provisionsol'Cl apter9(comencing with
I hereby affirm
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fullF )BnddfDivision3of the Business and professions Cods, and mylicenseis in
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PANELS
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Fye
LicmxcClasexact.
License Clens LIC.# .J /�O #�s
UPT0200 AMPS
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Date — ¢¢--ConuacmrV
201. 1000 AMPS r
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Cy71TECTS DECLARATION S'zlojc �
OVER 10011 AMPS
19 Null
� F OR AREA S/SQ. I.T.
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1 understand my plwrs shell M used as public records.
IF AL
SIGNS ELEC IUCAL
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Licensed Professional
SPECIAL CIRCUCDMISC.
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OWNER -BUILDER DECLARATION
I hereby affirm that 1 an exempt from the Cornmcmrs License Law for Ne
]031.5. Business Professions Cade: My city or county
'TEMP. METER OR POLE INST.
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following minor. (Section and
which taluires v permit to construct, alter, improve, demolish, or repair any •uucmm
F) ATE
prior to Issuance, also requires the applicant for such #manta, fileusi,mal,lmemem
POWER DEVICES
that he is licensed pumuam to the Provisions of Ne Contractors License Taw (Chapter
a,<0
`a t] 0
9(commencing with Section 7")of Division 3 of de Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
xoa
,no,
or that he is exempt therefrom and the basisfor Ne alleged exemption. Any violation of
fur. he of
OUTLETS - SWITCHES - FIXTURES
/�/)�!
y�/
FZQSection)031.5
iSp
by any applicant permit sCol.,, applicunLto a civil penalty
not mom than five hundred dollars (5500).
NEW RFSIDENTIINLELECIR _SQ. FT.
STORIES TYPECONSTRUCIION
���❑
I,aown«o(Neproparty,ormycmploy«swithwegexatheirsolecompemedon,
will dotbe work.and thmuucture is not intended proffered formle(Sec.9044, Business
and Professions Gude: The Contractor's license Law does not apply to an owner of
pmpeny whobuildsor improves Ncreon.andwhodcessuchwork hintxlfm Owughhis
OCC GROUP RIS. UNITS
s, providedsuch improveramotarcnot lmendedoroffered formle. If.
employ«thm
however, the building or improvement is sold within one yearof complerion, themsom.
TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sales).
QTY. PLUMBING PERMIT
FEE FLOOD ZONI: APN
❑ La-uwnero anexduss
Col ensMe
Contcbtalo
ad Proacting,
onama he pmj«t (Sec. ]OW, Business acted Professions Cal J The Contractor's
m (SCC.
License Lew Jcesnot apply to an ownerpfproperty whabuilds orimproves Nercon,end
PERMIT ISSUANCE
whocontmcu for such projects with.contractors) licensed parsaavUu the Conuacmrs
ALTER - DRAIN & VENT - WATER (EA)
FC•E SUMMARY
License Law.
❑ 1 am exempt under Sea B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR. ROOF, ARG.CONU.
RECEIPT#
SCHOOLTAX Y N_
.
❑ IM1ercby nffimtthall haveacenifica¢of<Unseen nwdf-insure,macerlilicate of
FIXTURES - PER TRAP
RECEIVI#
Workena Compensation lmumncem a Certified copy flmorf(S«. 3800. UmCJ which
PARK FEE Y N
RECEIPT #
Covers all employ«sunder Nis permit
Policy #
GAS - EA. SYSTEM -1 INCA OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM.OVER 4 (EA)
PLANCHECK FEE
❑ Ceni copy is hereby furnished.
Wiled copy is Elul with Ne city insp«lion divicion.
GREASEANDUSTRI, WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
Miss«tion need not becompleted ifthe permit is forone hundred dollars ($100)
SEWER -SANITARY- STORM FA. 20041',
ENERGY FEE
Ic certify Natio be performance of Ne wart for which this permit is issued, lshall
WATER HIi1TFR WNENT/ELECfR
not employ any person iq cQso u to become subject to the Workers'
PAID
Campensmionlawsof Califo f
WATER SYSMMjUUdV TNG
Dmc Receipt III
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Applicant
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NOTICE TO APPLICANT If,afte n dng Nis Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
In
become subject to Ne Workers Compensation provisions of Ne Labor Cade. you must
rm
forthwith comply with such Provisions or this Permit shall lx d«mcd revoked.
BUILDING ILC
a?
a (]
CONSTRUCTION LENDING AGENCY
SEISMIC FEE 'YJ
z
1 M1emby affirm Nm there is a construction lending agency for Ne performan« of
TOTAL:
F,LCCfRIC FEE
U0
the work for which this Permit is issued (Sec. J09], Civ. CJ
Landers Name
PLUMBING FEE
'L' F
Isnders Address
QTY. MECHANICAL PERMIT
FEE•
V
I certify that I have mad this app cation nd note Nat Ne above inf smadion is
MECHANICAL ME
Correct. lugr« m comply with all city and eaumyordinunees andswm laws rclaing m
PERMIT ISSUANCE
I--'
building construction, end herebyvuthorism represenmtives ofthixcity to enter upon the
CONSTRUCTIONTAX
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aline -mentioned properly for inspection purposes.
ALTERORADDTOMECH.
(We) agree m save, indemnify and keep harmless Ne City of Cupertino against
Iimedities,judgments.asstx andexpeassawhich may in any way accrue against said City
AIR HANDLING UNIT(101B.WU CFM)
inconsequence a grealingof Nis pemot.
—0� 3AIR
HANDLING UNIT(OVER 10.00k)CFM)
ig Ulu p(Ap irro ummetar Dale
EXfIAUST IIOOD (W4)UCIJ
PAID
IIAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU)
Data Receipt a
Will Inc appllcam or furore building occupam store of handle hmardnos mpmnd
HEATING UNIT(OVER 100.0aid BTU)
TOTAL: �
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)1
VENTILATION FAN (SINGLE RISID)
11 Vex
ISSUANCE DATE
Will theapplicamorfmure building«cupantuxequipmentordevi«swhichemit
BOILER- COMP (311P OR 10000d BTU)
sr' D
A
hvrmdaus air oniaminams as del and by the Bay Area Air Quality Mmmgenlem
BOILER. COMP (OVER 100d)(00 BTU)
..
District?
.O�
❑ Yes YS No
NEW RESIDENTIAL MECH. 50. IT.
2 R 993
MAY �s#v#v#
I have mail the Imour pun materials requirements under Chapter 6.95 of the
^ v
Cnlif.mia I1.1hh & Safety Code, Seetiona 25505, 25533 and 25534. I understand thin
if no building does not curently have a tenant, that it is my respnmibiliy to notify the
CITY Ur k.,Uf CMIBxIU
t of Nem ¢ which must be met m ce Of. Cerificare of
occupan q��JJs��/
iii
1
Data
'TOTAL:
ISS