25420 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL DI - CTRICAL PERMITNO.
APPLICATION/PERMIT PING FROG-MECHANICAL 25420
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: n SANITARY 0. APPLICATION SUSUBMITTAL DAT
fQ/V Q C /F/D 714'UNl\<
LOT
OWNERS E; PHONE: CONTRAC O `A E: I.IC NO:�O
!C e t NIC CONTROL#
,•CONTACT:
CT/ENGINEER: LIC ADDRPfg:2-7 C PA,m�w I ^ ^- ix NAu
CONTACT: PHONE: . •S / •f \ J % BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG L P UM A{ECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
M=z Ihcoh iffrm thall.m licenseximahamirwisi....f Chapar9(commeneingwith
R)OO Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
FFy"�+IC Poll force endeffec.
<z,WUry L'a Lic.# �U 7 UP T0200AMPS
rFii Qty a Gtunhmlm 5VER IW O MPS
AMP
ZFOy� ARCHITECTS DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA S/SQ.PT.
CZ-0
1 understand my plans shall be used es public records.
SIGNS ELECTRICAL
Licensed Professional
S qo'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
yi5AFF 1 hereby affirm that I am exempt from the Couturiers License Law for the
tr✓'3 R-an following..an..(Section 7031.5,Business and Pofessiom Code:Any airy m county TEMP.METER OR POLE INST. _
,1 which requires a permit o consumer.alter,improve,demolish,or repair,any ewcmrc
rn>:� primoits issuance,also regmres the applicant forsuch pennnofilesigned statement POWER DEVICES
W0O that he is licensed pursuant to the provisions tui the Contractor's License Lew(Chap¢,
Lye9(eummencing with Section 90W)oFDivislon3af the Business end Profeeslons Code) SWIMMING POOL ELECTRIC �x _ VALUATION
or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUTLEfS-SWITCHES- 1/V�`��J
F 4 Section 7031.5 by any applicant for a panni[subjects the applicant to a civil penalty of FIXTURES
O not mom than five hundred dollars($500). NEW RESIDENTIAL ELECfR S FT.
f1 ❑ I,esowneroftbeprnparfy,ormy employeeswith wages estheiraolecompensadon, Q' STORIES TYPE Cf TRUCf10N
'I. will do the work,and[heswcore ominintendedoroffemd fielate((Spe704,1,Business
w
and Professions Code:The Conctot's License Law does not u o an owner of
property who bui Ids or i mproves thereon,and who does such work h i mself or through his
provemen I ,, OCC,G OUP NITS
ever,he boldin for improvement
thin ne earefoomplfered for he owmar- /
howevegtheave the burden oprovinisaolde didnoneyear of cprove foron,tarposer- I��� Jy
builder will have the burden of proving that he did not build or improve far purpose of '
sale.). TY. PLUMBING PERMIT E ODDZ NE PN
❑ 1,as he project
property, .Business
lad Professions
s with sedTh Covc�thantractors
Q DATIfL
umaaum the projen(Sec?044,Business and ywhobuild Code)The Commcmrs !�
License Lawdforsucapplytoanowneofpoped)[ic builds Coreon,and PERMIT ISSUANCE
whoamraw.formch projects wiNecannamor(s)licensed pursuenuo the Contrecore ALTER ( ) FEE SUMMARY
License Law. WATER EA
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT'.DEVICE ------------0—MODE—FEES
SANITARY YN
Owner Dam RECEIPT#
WORKMAN COMPENSATION ofam DECLARATION DRAINS-FLOOR,ROOF,AREA,COAD. SCHOOL TAX Y N
❑ .'C.yaffirtn that lhave ecenificeo of wnsenno self-insure,oracenificete of RECEIPT#
FIXTURPS-PER THAT Workem Ctumpensationlnsumnceoocertified copy thereof(Sec.3R00,L.b CJwhich A PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIP #
Policy# BUILDING DIVISION UP
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKFEE
❑ Cerlifiedeopyisherebyfumishad.
❑ Certified copy is filed with the city inspection division. GREASPANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rad not be completed iffle permit is fortune hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
in lass.)
I readily that in the c of Ne work for which thio permit is issued,IsM1el1 WATER HEATER W/VENT/ELECfR
not employ nny parse in mar so as to become subject to the Wmkers' pplp
7-. pensation Laws of 1 . Date WATER SYSTEM)TREATING Date Receipt It
Q pplicam
NOTICE TO APP ,after making this Certificate of Exemption,you should NEW RESIDENTIAL PUSH. SQ.PT'. TO
become sdhja the Worker pensation provisions of the Labor Code,you most
forthwith comply with such pm ismns or this permit shall be deemed revoked. BUILDING FEE
z ' ere CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that this a construction lending agency for the performance of ELECTRIC FEE
U O the work for which this permit is issued(Sec.3099.Civ.C.)
LIr Lenders Name -
U Lenders Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
I certify that I have mad this application and state that the above Information is
W cored.(agree In comply with all city and county ordinances and elate lawarelating to PERMIT ISSUANCE MECHANICAL FEE
rFi V) building construction,and hereby suNoriu representatives of this city to enter upon the
CONSTRUCTION TAXU above-mentioned property for inspection ALTER OR ADD TO MECH.
We agree m save,indemnify and kip harmless due Ci ty of Cupedino ng®rat
liabilities,judgmenrs,costs ands .,as which mayinany way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
In consequence of lha this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
ignature of LCAKOBlak, Data EXHAUST HOOD(W/DUC)
PAID
"c IIAZARUDE MATERIALS DISCLOSURE HEATWG UNIT GO 100,000 BTU) Date Receipt
coat the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as def red by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section x)
Yes '! ❑No
❑Yes VENTILATION FAN(SINGLE RESID)
Will thea licanmrfuwrebuildln BOILER-COMP(3HP OR 100,000 BT1J)
ISSUANCE DATE
pp gby the
Ana
Air Quality management
Daniel? air contaminants as defined by the Bey Areae Air Quality Management BOILER-COMP(OVER 100,000BTU) P A I D
Distrin? Y- Pi
l ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazafdous materials requirements under Chapter 6.95 of the AUG `�
California Health&Safety Code Sections 25505,25533 and 25534. I understand that 199102
ifthe building does not currently have a tenant,that it is my responsibility to notify the
mccupam of the cande a is which must N met prior to issuance of a C nificaa of fsf1� MY�tI�#(�y
Occupancy. V11 VU thy"i/
Owner or ardamard.gent Data L. ISSUED BY:�
OFFICE