25862APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELEC I R1 n.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
It UILDING PIt(1JRCI' WENTIFICAT'ION
PERMITNO.
25862
BUILDING AUDg1i55: S& /� ` A UNIT# LOT
11{. 1/AMR::/V
SANITARY NO.
APPLICATION SUBMITTAL DATE
NBRSS'AMF::
/
CON ACfOR'SN LIC NO:
NIC
❑
CONTROL#
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iIIONE�
ARCHI'I.CT GINEHR: LIC NO:
ADDRESS:
:ONTAACI'; PHONE:
QTY. ELECI'ItIC PERMIT FEF.
BUILDING PERMIT INFO
BLDG fL[Cf PLUMB MF.CH
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PERMIT ISSUANCE
0042
P00
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171
LICENSED CONTRACTORS DECLAMATION
I hereby affirm that l um licensed under provisionsidChupterY(commencing with
Section 711W)OTDivision Sot' the Business and Professions Cude,and my license is in
full force and effect.
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
,` 1T
I PANELS
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;
License Class Lic.p
Date Cme ru,tor
UP TO AMPS
`
201 -1000 AMPS
ARCHITECPS DECLARATION
I understand my plans shall Its, used m public records.
OVER I"AMPS
SQ. FT. FL00 AREA $ISQ. FI'.
O
SIGNS ELECTRICAL
.N.
-0
License) Professional
mal
00. F
3rtrn
OWNP.R-BUILDER IIECLARATION
1 hereby affirm shut 1 am exempt from she Contractors License Law for the
following mason, (Section 7031.5, Bminess and Professions Code: Any city or county
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
-'o,n
which requires a permit to consumer, edict. improve, demolish, or rcpuir any structure
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y_y
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yro
pricrto its issinn«, also requires the applicant forsuch ponniuo flea aignedatmement
that he is licensed pursuanfto the provisions of the Comremor's License Law (Chapter
9mommencing with Section 7000) of Division 3 of the Business and Professions Code)
or h7031.5 by therefmmand nt for a basis (onhealleged exemption. Any violation of
Seaion]W LS by any vpplica, mr, ermit subjects the npplicanno vcivil penvlty of
,.than five hunit 1111 ($500
I, usownerollhe nSTORI
Prnpm y,ormyemployeeswithwagesmmeirmlecompen.cation,
will thewons and e, Me Cumisnm Mwdede Law ed does not apply. to sm Business
send Pro'resinns Code: The Cnntrazto/s License Law does not apply m an owner of
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
/� �#xY
!/ U VV
OUTLETS -SWITCHES -FIXTURES
NHWRBSIDENTIALMUCTR—SQ.Irl'.
,.' T'YPP. CONSTRUCTION
(S p /s tt t� s..� rr rs
\SII /^_\\ IPS.., I' L Ill
I
property whobuilds «improves thereon, and whndoes such work himselforlhrnughhis
n employers, Provided that suchimprovemeres arcnot imendedoreffered forsale. If,..
11 L\Qy
QC P •� S. UNITS
t �
however, the building crimprovement is sold within one yearofcompdetion.the owner-
hnilderwillhave theburdenofproving Ihuthe Aid norbuildmim,rove forpurpose if
TO 7
D V\ J P� i
QTY. PLUMBING PERMIT FEE D
sale.).
❑ 1,mawnerofthepmp,ny,amexclusivelymntwtingwithilcenudeonmctorto
TE F1.OfDZfNk0AI'N
construct the project (Sum. 7044, Business and professions Code:) The Ciatmelm's
License I.vw d«s not apply m un nwnernf prnpeny who builJs err improves thererm, end
PERMIT ISSUANCE
who contmets for such Projects with a rmaracmr(s) licensed purswnuo the Contractor's
License Lins.
ALTER -DRAIN &VENT -WATER (PA)
FEE SUMMARY
❑ I vat exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
Owner Dam
DRAINS- FLOOR, ROOF, ARM. COND.
SANITARY YN
RECEIPT #
WORKMAN COMPENSATION DECLARATION
❑ Thereby nffrm thalhuveucenifcate of amsenno self -insure, ora cetlifcute of
Workers' employeesonder ermit. ifiedcopy thereof (Sec. 38(10, Lab CJwhich
SCHOOLTAX YRECEIPT# N
FIXTURI3-PER TRAP ���
PARK FEE Y N_
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
thus
n all employee's under this peonif
Policy #
RECEIPT' M
BUILDING DIVISION FF.E.
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑Cenifed copy is hereby famished.
OREASBBNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CertifrA copy is fled with the city inspection division.
CHR'TIFICATB OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM FA. 200FIL
ENERGY FEE
(This section need net he completed Ethe pcnnit is foronehundred dollars (SIM)
Or to..)
WATER HIiVEER WNENT/ELECI?
I ecnify that in the performance of the work for which this permit is issued, l shall
not employ any rr.a in any manner so as to become subject to the Workers'
PAID
I z
Compensation Laws of Celifomia. Dam
Applicant
WATER SYS'I EM(rREATING
Dam Receipt#
C,
Let
NOTICE TO APPLICANT:If. after making this Certificate of Exemption, you should
bewmc subject o the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMIL SQ. FT.
Tal'AL:
BUILDING PER
forthwith comply with such provisions or this Permit shell be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
z
O
1 hereby affirm ilia, there is a construction lending agency for the performance of
the work for which this perm, is issue) (Sec. 3W7, Civ. CJ
Lender's Name
T
ELECTRIC FEF -4
Leaders Address
QTY.- MECHANICAL PERMIT '.ITE
PLUMBIN r�
'F
I cenify that I have read this application and stn, that he above information is
to comply with all city and county nrdinnnmw and stain laws plating to
ction, and hereby authorize representatives of this city to enter upon Ne
d property fur inspection purposes.
U
0.
fA
z
PERMIT ISSUANCE ��
MECHANI FE fs
AI:1'ERORADOTOMECH.
CON' RII ION TAX
to s ,indemnify and keep hanNus the City of Cupertino ngaimt
99.
en¢ oisandexpe. s ay in an"tryaccru, agalmtsaid City
AIR HANDLING UNIT(TO 10.000 CFM)
ofdt gr ming th
AIR HANDLING UNIT (OVER 10,000 CFM)
O/ �y
l lDute
.ig nurc of pplicant nmrnnor
EXI MUST HOOD(W/DUCp
PAID
]I RATING UNIT (TO 10G." BI U)
IIAZARDO ' MA IAM DISCLOSURE
Date Receipt #
Wi pplicanmrfuwre tiding capstan pore or handle hazardous material
us delinnl by the Cupertino Muni, al Cod Chapter 9.12, and the Health and Sufmy
IIIiATING UNIT (OVEN IW,ftIXI BTU)
TOTAL:
Cade, SecdJ2(e)7
❑ Yrs ❑ No
VENTILATION FAN (SINGLE RESID)
Will the appli,amorfnumbolding«cupam umequipmentordevlees whichemis
haraNam air comamiwds we defined by the Bay Arca Air Quality Management
now?
BOILER- COMP (31 IF OR I(fl," BTU)
ISSUANNE DATE
BOILER - COMP(OVER 100.000 BTU)
❑Yes ED No
PAID
NEW RESIDENTIAI, MECII. SQ. FR
1 have read the hazardous materials requirements under Chapter 6.95 of the
California health & Safety Ctde, Sections 25505, 25533 and 25534. 1 understand that
if the building doa
es ant mend, have a mount. that it is my respomm0ity to and fy the
JAN 7
cupam of the rental ... 1. which most be met prior to housnce of a Certificate of
/
O.apunmy.
to
Owner or authodzed agent Date
TOTAL:
ISSUP.D BY MR, 1tk I
OFFICE