25550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bun.BI i-ELECTRICAL PERMIT NO, n r�S IaIa���� FFO
APPLICATION/PERMIT PLUMB ING-MECIIANICAI.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 2 V V V
RUILDING ADiSRESS; SANITARY NO. APPLICA'f10NSUHMf1.1'ALDA'1'li
6"7*
UNITN LOTH
OWAME �M4 PIIONB: Cr fR(I V, MN`i l`x 4WOAI 4-SC NO
_ �O� N/C CONTROLM
kRClll'IECf/ENGINEER: LIC NO: ADDRESS: GOr '-(1p
am
CONTACT: PHONE:
QTY, ELECTRIC PERMIT PCE BUILDING PERMIT INFO
BLDG GLECI PLUMB MITCH
PERMIT ISSUANCE 13 ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pKZ IhcrebY affirm that am licensed underprovisionxof Chepmr9(commcncingwith �w//Yrnii Al- V La--k IG*-
1400 Section]000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
ty fall force and ertcet. �N ��/� �g�
FZny U-m Lic.p `�'T`��mT UP TO 200 AMPS /� ✓�'��
m=y Dam Co.tracmr 201-1000 AMPS
777ri St
ZOyZ OVER IOW ARCHRECTSDECLAItAT10N tQ',FT.iLOOR rR9 8/SQ.FT.
AMPS �
OZ— I undetsmnd my plans shall be used as public records.
SIGNS ELECTRICAL
p��
qFy License)Rnfcssionol TER Y 1l
E wk!u OWNER-HUILDHR DECLARATION SPECIAL CIRCUIT/MISC. �g
N, 1 hereby�fd m that 1 am exempt from the CO..,,.,', La.',License Lbertha
a
aw following reason.(Section 7031.5,Business and Processions Code:Any city or county TEMP.METER OR POLE INST. AI
E;',Owhich requires a permit u)consrun,alter.Improve.demolish,or repair any structure
m io��a prior to its issuance,also rectums the applicant forsuch Permit file a signed statement POWER DEVICES
-
Mewp0 IM1et he is license)pursunm to Me provisions of the Comradnr's Lioense Law(Chapter
ddaLL 9(commencingwithSwtion]00Oof Dlvision3of Ne Busineesond Professions Code) SWIMMING POOL ELECT RIC VALUA'T'ION
W=,, or that he is exempt domfmm end the basis forthe alleged exemption.Any violation of v` O�
�Q Section 7031.56 ua t licunt for a permit subjects the applicant to a civil OI/TLFTS-SWITCHES-FTXTURF.S Co
Y Y t re Penalty of
not mnro than five hundred Jollws($SW).
❑ hmownerefNepropenriormyempluymswithwagesatheirsolecomNmation, NEWRESIDENTIAL ELECRt _gQ.FT. STORIES TYPF.CONSTRUCfION
a3— will Jn thewank,andthesnuc,ure is not intended oroffered forsale(Sce.]044,Business
and Professions Cod,I'to Contractor's License Law does not apply to an owner of
penny whobuildsmimpmeesimmon,grdwhodoes such workhimaelfordaough his OCC.GROUP RES.UNI IS
ownemployees,provided thetsuch improvemen,ssre nmimendetlorofferedforsale.If,
however,the building or improvement is sold within one year of completion,the mener-
builder will have the burden of that he did not build or improve TOTAL:
proving prove for Purpose of
ale.).
❑ I,nsownen,f the pmpeny,umexdusivntycunvoctingwiN license)contractors no QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(See ]044,Business and Professions Code:)'no Connacmh
License Lawdoes not applyto an ownerofpmpeny whobuilds or improves thereon,and PERMIT ISSUANCE
who connotes for such projects with o connucnons)licensed puouam to the Commemre
License Law. ALTER-DRAIN&VENT-WATER ILII "FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far Nis reason BACK FLOW PROTECT'.DEVICE OUTSIDE 'ES
SANITARY Y_N
Owner Data DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ Iherebyrifirm thin l have u certificate ofconsemno self-insure,marrudit3moeof FIXTURI?S-PGR TRAP RECF.IPTp
Wrrkemon
'Compemadon lmsuceor a cenified copy thercof(Sec.3800,Lab C.)which PARK ITE Y N
coven all employees tuner ds permit. RECEIPTp
GAS-FA.SYSTEM-1 INC.4 OUTLETS
Policy p BUILDING DIVISION FEES
Company GAS-P.A.SYS'T'EM OVER 4(EA) PLANCRECK FEE
❑ Ce.ifiedcopyishercbyfumished.
❑ Cenifed copy is fled with the ciry inspwtian division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR FSH TRAP SOILS IEE
COMPENSATION INSURAN
(This section nem not be mmplemdif the pentoIi one hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEB.
or less.)
Iccnifythatm Nepcdo ss kfo vhichnhispermitisi.mad.Jshall WATER HEATER W/VENT/ELECIR
not employ any pertv o in y in t heaame aubjecn m the Workers PAID
Compensation f and
am WATER SYSTEM/IREA']ING Dam Receipt
O sem- APPlicant
0 NOTTCETOAPPLIC T:lf ter making this Certificate of Exemption,you should NEW RESIDENTIALPLMB. SQ.FT. TOTAL:
p] beemnesubjecltothe Workc Cneopersionn provisrmn.fthe Laborda Coyou must
Ix 7 forthwith comply with such provisions or this Permit shall he decided invoked. BUILDING FEE
1 2 CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby hithaffirm(Nat thein is a construction lending agency for the performance of
the workfor which phis permit is issum(Sec.3097,Civ.CJ TOTAL: LLECfItIC FEE
Lender'a Name PLUMBING THE
O F Lenders Address QTY. MSCI IANICA1,PERMIT FEE
U I certify that 1 have read this application and.irate that the above information is
0. contact.I agues,to comply with all city and county ordinances and stoic laws relating to PERMITISSUANCE MECIIANICAI.PEC
En building construction,and hereby au,honn represenmtivu ofthis city to enter upon the CONSTRUCTION TAX
U 7 ahove-mentioned pmpcny for inspection purposes. ALTER OR ADD TO MF.CH.
tom-
(We)agree no save,indemnify and keep harmless Npe
e City of Cupertino against
liabilities,judgments,costs and expenses which may in any way sectors against said City AIR HANDLING UNIT CFO 10,000 CFM)
in rins"oence of the gran,g of this pennou
�k� AIR HANDLING UNIT(OVER I0,000 CPM)
4 ,�_ EXHAUST HOOD(W/DUCT
'ignmure of APPli VComocu,r Dum PAID
HAZARDOUS MATFRIAM DISCLOSURE HEATING UNIT(TO BY),"BTU) Dam Rwc"'#
Will the applicant Or future building cecrpantsmre or handle haaardom mmerial HEATING UNIT(OVER ID0,000 BTU) TOTAL:
as deinm by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)] VENTILATION PAN(SINGLE RFSID)
❑Yes PN.
Will Neo licanuafumrebuiltlin tame mrdeviceswbich emir BOILER-COMP(3HP OR If0,IX0 RTU)
ISSUANCE DATE.
pp gwcupen quipmen
azerdous air contaminants as definm by the Bay Arta Air Quality Management HOH.ER-COMP(OVER IOQ(00 BTU)
knits'!
❑Yes NO NEW RESIDENTIAL MECH. SQ.FT. P A ID
I leave read the hazardous nmterialx requirements under Chapter 6,95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that SEP l g1�o�
if the building dors not emmidly have a mown,,that it is my responsibility m rotor,y Ne NV
pant of the require which mush be men prior no issuance of a Certificate of 14
Oc
4$ iy 93 CITY 7;f
wU ter ur amhoriu, ng t Date TOTAL: ISSUED BY: � VY
OFFICE