25443 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOBn¢Dmz'.ELEC IL'Al PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL n C �I /I
BUILDING DIVISION BUILDING PROJECT IDEN'I IFICATION L J 4 4
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
'1"/
OWNERS NAME: �Cµ �� PHONE. CON'I'NA OR'/S'NAME: �C NOL N/C CON'I'ROLK
r� A CHITECIK �IHER: IJCN ADDRESS: �J N �Q J ❑
V C/ ✓�/
CONTACT: PHONE: 141 s yt z. .
"`"',f-- BUILDING PERMITINFO
/I QTY.j.{;'y f �IAECTRIC PERMIT "'-- FCE
K BLDG ELECT PLUMP
SUCH
PERMIT ISSUANCE 11
LICENSED CONTRACTOR'S DECLARATION ❑ El 11
owz I hereby affirm that l am licensed underpmvisiomofCapter9(cotmnencingwith APPLIANCES-RESIDENTIAL JOB DESCRIPTION
199100 Section 9000)of Division 3 of the Business and Professions Code.and my license is in PANELS o1V
K fol l farce and effect,
F<z, Liceme Class Lick IIP TO 200 AMPS
,<M Data Concom 201-1000 AMPS
70 y'Z -ARCHITECTS to CTS DECLARATION I f� 6Q,.PfvlfLQpR pre � $/SQ.FT.
OVER IOW AMPS 111�- '\
O Z, I understand my plans shell be used a9 public records.
<N7: SIGNS ELECTRICAL �\/� ��
<y -� Licensed ProRssionnl \./ e
4p5Op-'< OWNER-BUILDER DECLARATION SPECIAL CIRC'I31T/MISC.
yU I hereby affirm that 1 am exempt from the Contractors License law for the R
W 3CLy following reason.(Section 9031.5,Business and professions Code:Any city or county TEMP.MCfER OR POLE MST. DATE V
�; which requires a permit to construct,alter,improve,demolish,or repair any structure
!(}:c primmicamsuance,also requires theapplimns forsuch pennho.fileasimadsm
mmem POWER DEVICES
= <0 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
tee. 0"1 9 (cammencing with Section](100)of Division3afthe Businessend Pmfessiom Cale) SWIMMING POOL ELECTRIC VALUATION
XWZm or 7031.5 mpt by any applicant for
the Permit subjects the
dexemant to civiny l
of OUTLETS-SWITCHES-FIXTURES qO�
t A nation 7031.5 by hundred
do]] orapemtit subjects the epplieanrtoeoivil penalty of VVV
notion re than five hundred dallvs(E500).
C ❑ I,mownerofthepmpcty,ormyemployceswithwageeasthairselecompensedon, NEWRFSIDENTIALELECTR _SQ.IT. STORIES TYPE CONS'IRUCI'ION
will dothe work,and the structure isnot intended conducted fmsale(Sca.7 4,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
pmp nywhmbuildsorimprovuthe n,endwhodoessuchwahhimselforthroughhis
employees,pmmmra
vided that suchimproveesanot itnendedoroffned forsale.If,
OC .GROUP RES.UNI'I'S
however,the buildingor improvement is sold within one yearofcompletion,the owner- TOTAL:
hullder will have the burden of proving that he did nm build m improve for purpose of
Sala.). QTY. - '' ''` PLUMBING PERMIT ITE ' FLOOD ZONE APN
❑ Les Project(Sm.
Business
Professions hlicensed Contractor's
License
the oesnot(gee9M4.Businev and Professions Code:)The Contmutand PERMIT ISSUANCE
License Lawsees such
applymmownercfproperty whobuilds or improves thereon,and
Lwho icni Law,
for such pmjectswith acnmrucmga)licensed punuannothe Conuuemr's ALTER-DRAIN&VFW-WAI ER(EA) ' FEE.SUMMARY
License Law. -
❑ 1 am exempt under Sec. ,B&P C for this teason HACK FLOW PROTECT.DEVICE SANITARY OU YE FEL.
N
Owner Data DRAINS-FLOOR,NOOE,AREA,COND. RECEIPTA
• cove WORKMAN COMPENSATION DECLARATION SCHOOL)'AX Y
❑ Ihercbyaf6tm@utlhounce or iftcam ofcowemmwf(Scsum,a aaroficam of RECEIPI'a
Wodcrs'Compensation lnxusvnce oracenified copy thereof(Sec.3gW,luCCJ which Fl%TURI'S-PER TRAP TANK FEF. YN
covers all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT a
Policy g BUILDING DIVISION FEES
Company GAS.EA.SYSTEM OVER 4(EA) PLANCHECK IFC
❑ Cedlfted copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS21RAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forone hundred dollars DIW) SEWER-SANITARY-STORM IA.200FT. ENERGY ME
or lass.)
I century that in the performance ebbe work for which this permit is issued,l shell WATER HEATER W/VENT/ELECfR
not employ any person in any summer so as to become subject m the Workers PAID
Compemotionlawsof California. Data WATER SYSTEM/TRfLVDNG Dam Receipt
O Z Applicant
NOTICE TO APPLICANT:If,after making this Cmfificeteof Exemption,you should NEW RESIDENTIAL FINE. SQ.FT. TOTAL:
rn become subject o the Worker's Compensation provisions ofthe Tutor Cade,you most
tee^ ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING ME
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Nat them is a construction lending agency for the pefformunce of
L) O the work for which this permit is issued(See,W.Civ.C.) TOTAL: ELECTRIC FEE
Landers Name - - PLUMBING EEE
f
Lenders Address QTYe ' ` MECHANICAL PERMITS FEE
O V 1 certily thin I have rcae this application and orate that the above information is a" -
� correct.lagrcemcomply with ell city and counry oNinences end state laws relining to PERMIT ISSUANCE MECHANICAL FEE
_
construction.and herebyauthorize represenmtivesofthis city to enterupnn the CONSTRUCTIONTAX
L) z above- tinned property for inspection keeppurposes. ALTER OR ADD TO MICH.
(We) ret to save.insemnify and kap harmlea the City of Cupctino against
Iiabilitia,ia mats,co nd expenses which may In uny way stern .'are,t said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
inconsequence fth num,nftttispppeeeomit
r/D AIR HANDLING UNIT(OVER 10,000 CFM)
mm Apps t/Contractor O- ate EXHAUST HOOD(W/DUCI) PAID
ZANUO IALS DISCLOSURIi
HEATING UNIT(TO 100,000 BTU) Date Raeipt M
Will applic t or future building manners score or handle hazardous material HEATING UNIT 1W,IX10 HTU) TOTAL:
es defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'1 r VEN'T1LA
❑Yes ❑No TION PAN(SINOLI3 RI?SID)
Will theupplicantor futurebuildingoccupant useequipmemordeviceswbich emit BOILER-COMP(311P OR 100,000 BTU) ISS 1CB+DATE
• hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000B rut A'f� O {{II�
District? 11 V
Yes ❑No NEW RESIDENTIALMF.CH. SQ.FT. O
1 have mad the hazardous materials requimments under Chapter 6.95 of the Cly VP ` J
Cnllfbmia Health&Schly Code,Sections 25505,25533 end 25534. 1 understand Nat LtrCf7
it the building does not currently have a tenant,Nal it is my responsibility to notify the
caper of the reGuircmenls which must be met prior to issuance cf a Cer iftals of
Occupancy.
Owner or authorizedagent Datc TOTAL: ISSUED BY:
0