25877x APPLICANT TO FILL IN INFORMATION WITHIN RED LII
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
ST2J ENS
POINT PEN ONLY
-BUIL IST.S7:. EITI77R1CAc
PLUMBING - MECHANICAI.
UNIT# LOT N'
S Imkk
FEESUMMARY
FYMIDZ9lYY:T.�1�C�
BUILDING DIVISION FEES
VLANCIIECK FEE
GRADING FEB
SOILS FEE
ENERGY FEE
PAID
Date Receipt#
BUILDING FEE
SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAI. FEE
CONSTRUO'1'ION TAX
PAID
Dale
C1ryo. L;UrtHllNO
ISSUED BY:
25877
QTY. ELECTRIC PERMIT. FEE
PERMIT ISSUANCE
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W
LICENSED CONTRACTOR'S DECLARATION
I herehyaffirm that l am licensed under provisionsm'Chapter9(commeacing with
Scene. 7000) of Division 3 of the Businessand Professions Code,and my he,. is in
full force and elleyn�Q%� //]��f �q
License Class {'G,Jfe # 447696
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201 - 1000 AMPS
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on
Dale Cmanmlor
ARCHITECTS DECLARATION
1 undetsmnd my plans shall Ix used as public records.
OVER IOOGAMPS
SIGNS ELECTRICAE
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby amen that 1 stn axelttpt from me Contractor's License Law for the
fallowing mason. (Section 7031.5, Business and Professions G+de: Any city or county
SPECIAL CIRCUITIMISC.
TENIRMETERORPOLEINST.
ted
��>�miss
WK 0
d0.o ff
which requires a permit m construct, elteq improve. demolish, m repair any Someone
prior requires PP Penni get
issuonee, also Thea licam for such no Rlcesi Natmemert
that he is licensed pursuant to the provisions of the Conlnnor's License law (Chupter
9hommencing with Section 7") of Division 3 of the Business and Professions Cade)
POWER DEVICES
SWIMMING POOL ELECTRIC
W_m
F. p Q
yam
m
a3—
or he is exempt M1erefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permapplicant it subjects the applicano a civil penalty of
nal mominan five hundred dollars(SMU.
❑ I, asowneroflncpropeny,ormyemployees wit wages astheirsolecompensation,
Business
will dothewna,Cde:
OUTLETS - SWITCHES - FIXTURES
NEWRESIDENTIALELECfR_SQ.FT.
s License Law does not apply tom owner of
end 1', Ilmetureisnm',Jamm, Lawrdosnote(SmJ0ran
oIm Core:'Itte
who ess fuerem such wdedeork rmelredforsale. ghhis
over lh
erry wyees,
ownlaropdsvidedt improvemerwaoes
If,
employees,rmvmenmprovement improSomemhin notiearofco
- TOTAL:
pllreredrne on. theown
milderhowevegillhathe building theburimpmprovinishat he ii noneyar ofcomplveforprowner-
hullder will have the burden of proving than he did not build oz improve for purpom nl
QTY. PLUMBING PERMIT FEE
sale.).
❑ I, as rtd'tepmperly,am eulusively conlretling wit littnuJ contrenorsm
construct the project (Sm. 78:4, Business and Professions CNet) The Contractor.
License law does not apply m m owner of property who builds or improves themoa,and
1 PERMIT ISSUANCE
who contracts far such projects with a comractorts) licensed pursuant to the Contractor's
License Law.
ALTER-DRAIN&VENT-WATER (EA)
1 am exempt under Sec. , H & P C for this reason
BACK FLOW PROTECT. DEVICE
tuner_Dade
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND.
' FXTURES - PER TRAP
I hereby affirm that l have a certificate of consent to self -insure, or a certifcatc of
keit Compensation Insurance or a minified copy themof(Sm. 3800, Lab C.) which
GAS - PA. SYSTEM -.I INC.4 OUTLETS
covers all employee's under this pefmit.��9 �3r/S� _
.
- �4 YI
Policy# - - Qf
Company N nn 7
GAS - PA. SYSTEM-OVER4 EA)
❑ Certified copy is hereby famished.
GREHASIVINDUSTRL WASTE INTERCEPTOR
❑ Certi Oed copy is filed wit to city inspection division.
CERTIFICATE- OF EXIIMPION MOM WORKERS'
GREASF.TRAP
COMPENSATION INSURANCE
SEWER - SANITARY - S'T'ORM IA. 20OF11.
Gins section need not he completed if the permit is forone hundred dollars ($100)
or less.)
WA*I'IiR II EATER WAITUNHIELECI'R
I certify lhal in tneperfofarro.of the work for which In, permit is issued, Ishall
not employ my pemon in any manner so as to become subject to the Workers'
Q z
Z 0
Compensationlowsof CWifomia. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
WATER SYSt'EM/IREATING
NEW RESIDENTIAL PLMIL SQ. FT.
rq
a
become Subject [.,he Wmkc's Compensation provisiawof the tabor Core, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
4k1 Q
z
CONSTRUC'T'ION 1. ENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
U O
Q F
UI
r1'
E-' OV4)
Uabove-mentioned
the work for which this permit is issued (Sm. 3MG, Civ. C.)
Lenders Name
1
QTY. MECHANICAL PERMIT FEE
Leaders Address
certify that l have need tis application and stale that the shave information is
correct. I agreem comply witall city and county ordinancesmdmate laws relining In
buildingeonstmetion, and hereby zulhonzempresentatives of this city to enter upon the
property, for inspection purposes.
PERMITISSUANCE
ALTER OR ADD TO MSCI I.
(We) agree it) save, indemnify and keep harmless the City oPCupe Lino against
litbilitics,judgmelns, costs andexpersw which may in any way accrueagainmsaid City
AIR HANDLING UNIT (TO I O,WD CFM)
in consequence of the glantin ftia Perm. a
4 -7
'G[ 140-7
AIR HANDLING UNIT (OVER 20.050 CFM)
EXHAUS'1'IIOOD (W/DUCT)
Signature of ApplicamlContractur Dam
HEATING UNIT (TO 1011,0311 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicaul or home building occupant smm or handle hazardous mmcdel
m defined by the Cupertino Municipal Code, Chafer 9.12, and the Ilaahh and Safety
HEATING UNIT (OVER IlN1,IXMI BTU)
VENTILATION FAN (SINGLE RE.BID)
`•
Cede. Section 25532OU?
❑ Yes .Rl No
BOILER- COMP(3HP OR lO),OW BTU)
Will the appi imam or future nu riding aecupanl Use equiinamt or devices which emit
BOILL'H - COMP (OVER IOUJIUU BTU)
hazardous alt ,,of a num, as defined 1, the Bay Are. Air Quality Management
District?
❑ Yes )�No
NEW RESIDENTIAL MI CH. SQ. FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
Culiromia Health & Safety Cade. Sections 25505, 25533 and 25534. 1 understand that
if the building does not curmally mv... e t.that it is my responsibility to notify the
trocar l nl'thhle rreyu�ima(re�cal wh/lu�h mJu+yyyyy�heA9ml print,, issunnco Off o Cenifienno of
.
Occupancy. /T�a+tii 7� I lto— I
owner or authnrizN agent Dale
TOTAL:
., OFFICE
S Imkk
FEESUMMARY
FYMIDZ9lYY:T.�1�C�
BUILDING DIVISION FEES
VLANCIIECK FEE
GRADING FEB
SOILS FEE
ENERGY FEE
PAID
Date Receipt#
BUILDING FEE
SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAI. FEE
CONSTRUO'1'ION TAX
PAID
Dale
C1ryo. L;UrtHllNO
ISSUED BY:
25877
ANITARY NO.
APPLICATION SUBMITTAL DAT Ii
�__6 _q 1
NIC
. CONTROL #
BUILDING PERMIT INFO
ILDG
ELECT PLUMB MECH
❑
❑ J ❑
JOB DESCRIPTION
S Imkk
FEESUMMARY
FYMIDZ9lYY:T.�1�C�
BUILDING DIVISION FEES
VLANCIIECK FEE
GRADING FEB
SOILS FEE
ENERGY FEE
PAID
Date Receipt#
BUILDING FEE
SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAI. FEE
CONSTRUO'1'ION TAX
PAID
Dale
C1ryo. L;UrtHllNO
ISSUED BY: