25248 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OrCiJPERTINO
BUIL ;NG-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25248
.'BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
G ,
1 UNIT#
LOT
OWNERSNAME: P E: CONTRACTOR'S NAME: LIC NO:
/ r
NIC CONTROL N
ARC /ENGINEER: LIC NO: AD ESS:rr " ❑
ONTAC'L PHONE:
QTY. - ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL /OB DESCRIPTION
C7Cz Ihereby affirm thin l amlmensed underpmvisionso'Cbaprer9(comment th
4r 00 Section 7000)of Division 3 of Ne Businessand Professions Code,and my'loan i PANELS V.
CW full fame and effect.
Fy License Class LIC.# ` UP TO 200 AMPS
m GGA
Data Counter r 201-1000 AMPS
.z FO,z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA • $/SQ.FT.
I understand m 1 shall be used as public records. OVER 1000 AMPS
OZi ypense a
Licensed Professional SIGNS ELECTRICAL
� tyU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
00.F I hereby affirm that 1 am exempt from the Contractor's License Law for the
W 3 LLoe following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
a,'I which requires a pemdt to construct,alter,improve,demolish,.,repair any awemre
yN� priormitsinuance,also requires the applicant for such Permit file a signed statement POWER DEVICES
tp�QOq that he is licensed p-suanuo the Provisions ofthe Contractor's License Law(Chapter o.px.eLL 9(commencing with Section 700m of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELFCTRIC VALUATIOlco
W ern orthat he is exempt therefrom and the basis for the alleged exemption.Any violation of
'Y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES ��
not moreNan five huad`d dodanx($500). J
❑ I,asownerofNepmpay,ormyemployeeswithwagesastheirsolecoNnsation, NEW RESIDENUALELECIR _SQ,FT. STORIES TYPECONSTRUCION
L3� willdothe work,and the structure isnotimmndedoroffered for sale(Sec.7094,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
propertywho buildsorimproves dereon,and whodoes snchworkhimselforNrough his OCC.GROUP RES.UNITS
own employees,providedthat such improvements a renotinttndedorofferedfmrsale.If,
however,the building orimpeovement is sold within one yeamf completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
rule.). QTY. I . .. `PLUMB ODZONE APN
❑ hos the project
(Sm.
Business
sis and rolamin with license o Contractors
rs
License the project(Sec.oano Business and Professions Cade:)The Convector's PERMIT ISSUANCE
License Lowdces ac apply mawithacmmuclo s)ty whosedprorimpavvesratio Norton,and
whocontractsL.sfor such Projects with acontmcmr(a)1icenseJ pursuam mthe Contra<rors
License Law. ALTER-DRAIN&V - ATER EA FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT. OUTSIDE FEE
SANITAR Y N
Owner Date DRAINS-FLO OOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOO YN
❑ I hereby union that l have a certificate reorient or a cerifeem of RECEIPT#
Workers'Compensution Insurance or a certified copy thereof(Sec.3800,Lab CJ which FIXTURES-PER TRAP PARK FEE Y N
covers all employee's under this Permit GAS-EA.SYSTEM-I'INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished,
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is marine hundeaddollars($100) SEWER-SANITARY.STORM EA.201 ENERGY FEE
or les..)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER WNENT/ELECTS
not employ any Person in any manner so as in become subject to the Workers' PAID
z Compensation Lawsof California. Date WATER SYSTEM/rREATING Date Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If,after making Certificate of Exemption.you should NEW RESIDENTIAL PLAIL SQ.FT. TOTAL:
Cie) become subject o the Worker's Compensation provisions of the Labor Coda you must
5 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Ct. tr Lenders Name PLUMBING ME
Lenders Address QTY. `. ;, ;MECHANICAL'PERMIT, 'FEE
U I cerify that I have read this application and sam Nat the slave information s
W caret[ ordinances and m comply withal]city and county ordinaand state laws relay gto PERMITISSUANCB MECHANICAL FEE
Q.Q. building construction,and hereby authorise representativesofhisemty menter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way wan against said City AIR HANDLING UNIT(TO 10,OW CFM)
in conuquence fie ranting of Nis permit AIR HANDLING UNIT(OVER 10,00d)CFM) a
ger pylic C ruaor Dom EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU)
pan
R4ceipt#
Will the applicaator future building occupant some or handle hazardous material HEATING UNIT(OVER 10)(1,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 VENTILATION PAN(SINGLE RESID)
1:1Yes ❑No
ISSUANCE DATE
Will Ne applicamorfuturcbefined by the
equipment orality eanagement BORER-COMP(3HP OA 1(0,000 BTU) P^ A I D
hazardous air cnnmminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District9
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ��'ro 1 �aaJU��
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that
if the building does not currently have a Roam,that it is my responsibility to notify the CII Y Ur wrt
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: