25630 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - /)' C SANITARY NO. APPLICATION SUBMITTAL DATE
7 v `l�P NIT# LOTH ,0�LA C(�
NERS NAME:77.7& PHONE RACTORn'S AME: LIC NO:
ma�.LL9 �mON 4 ;fc Sp1r�_ /s� /pr NIC CONTROL It
A CHITECT/ENGIN ER: LIC NO: - S: VL L!�"� w
/L( 2 2 Sa-Aq-7ao4rsl- ¢yni{• ❑
CONTACT: PHONE:
I QTY. ELECTRIC PERMIT FEE -BUILDING PERMIT INFO
BLDGELE B MEC
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M=Z Ihereby affirm[hall am licensedunderprovisiomofCTapter9(commmcingwith JOB DESCRIPTION
OO Section 7000)of Division 3 ofthe Business and Professions Codpandmyliced isin PANELS
pdd1 UE full farce and effect. �� • /�it
6zzW LicenseC LiaY UP T0200 AMPS QWy� I/rJyl/n/'�c,
or
6 a Dme Contractor 201-1000 AMPS Rlrl I - s'�r' �/V TJ'✓
I"yI ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
2O'^ I understand mN plans shall be used as public records. OVER 1000 AMPS / IIIA`'
y W SIGNS ELECTRICAL
q' '� Licensed Professional
a W
OWNER-BUILDERm the CoATION SPECIAL CIRCUIT/MISC. I V T E R
iC O d I hereby affirm.(Se that 1 an exempt from the Contractors License Lew for the ifi'_ IgF.(l
W✓�w following reason.(Sermon 7031.5.Business and Professions Code:Any city mercury TEMP.METER OR POLE INST.
Hf�to I which requires a Penni[1.comwct,alter,improve,demolish,or repair any structure
Wad prior to its issuance,also requires the applicant for such permit to file a signedmidermant POWER DEVICES DA
T E
ly Ca O that be is licensed pursuant to the provisions of the Contractors L move Law(Chapter
4poG' 9(commencing with Section 70130)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VATU T
iW�m Seclathemsexemprn -PP
besmsfor Noets thednempti his
of OUTLETS-
2a Sec[ion]03 L5 by any epplicamfore permit subjats the applicant toe civil penalty of SWITCHES-FfXTURES
t more thanfioftheprve In eddollarmymp. NEWRESIDENTIALELECIR _SQ.FT. STORIES((!! TYPE CONSTRUCTION
ct ❑ Lmownerotlhepropeny,ormyemployeeswithwegesastheirsolecompensation,
In,
22 will dothework,and the structure isnotmatededmroffered formle(Sm.]044,Business _
and Professions Code:The Contractor's License Law does not apply Ito son owner of
propenywhobuildsorimproves Neuron,nndwhodoessuchworkhmmselfmB ughhie
ownemploms,pmvidedffiatsuchimpmvementsmwtintendMoroffmdforsale..If, OCC.GROUP RES.UNITS
however.the building or improvement is soldwiddrione yearofcompletion,the owner. T ��
builder will have the burden of proving that he did not build or improve for purpose of
cele.).
❑ Las ownerofthepmperty,etnexcluslvely convecting wiNlicensedcotractors to QTY. PLUMBING PERMIT FEE - FLOOD ZONE APN
consumer the project(Sec.7044,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does not applyto an owneroflompeny who builds or improvesthereon,and
who commas for emb projects with s contramor(s)licensed pursuant to the Contractor's
License Low. ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. ,B&P C for this reason OUTSIDE FEE
BACK FLOW PROTECT.DEVICE
SANITARY Y N
OwnerDRAINS-FLOORROOFAREACOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION , , , SCHOOL TAX YN
❑ ers'Co affirm
ereati Insurance oraficam ofcopythto self-insure,erof(Sm.380,Lab C.)au,ofwhich XTURES-PERTRAP / RECEIPT#
Wve..1 Cmployemio a&,thiis Insurance certifed copy thereof(Sm.3800,Lab CJ which PARK FEE Y N
RECEIPT#
covers ell emplmyee's under this permit GAS-EA.SYSTEM-1 INCA OUTLETS
[ BUILDING DIVISION FEES
icy#
any Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
allied copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if Ne Penni[is furore hundred dollars p$100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the performance of the work for which this permit is issu 1,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so ss to become subject to the Workers' PAID
Z Compensation Lawsof Ci iromia. Date WATER SYSTEM/IREATING Date Receipt#
Applicator
Q NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
h become subject to the Workers Compensation provisions of the Lehr Code,you must
FFFa"' forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE /•
CONSTRUCTION LENDING AGENCY SEISMIC FEE `
U z 1 hereby affirm[hat there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ,C.) TAL ELECTRIC FEE
Lender's Name
u' Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LUkII certify that 1 have read this application and stem that the above information is
move la,con,comply with ell city and county oninames and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
ybuilding communion,and hereby authorize representatives of this city to enter uponthe CONSTRUCIONTAX
U 7 above-mentioned property for inspection purposes. ALTERORADDTOMECH.
r1- (We)agree to save,indemnify and keep heartless the City of Cupertino against
h+lities,judgmen.......and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
knive of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
ignat ofAp< VC ` Wpnrtel r Dam (
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT GO 100,000 BTU) Date Receipt#
We bythe the Cupnt or ertino tore building Cock,C am smrc or hanand the
Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
al
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(.)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will lair co icaunacts air building by the
equipment mdevyc Management PAID
hazardws yr contaminants m defined by the Bey Aree Air Quality Management BOILER-COME(OVER 100,000 BTU)
Dis[dn? - '
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. ®A�
I have read the hazardous mnedns requirements under Chapter erso of the A (,
ifthe building
Health sSafety Code.Sections 25505,25533 andsponsi 1understand Net
mecopie ilofthe ucirements not whut hmust he that it is my responsibility[onmify the Q�iY Uh CUP '
O cupan[of the requvemenm which must be me[prim ro issuance a Certificate of
Occupancy.
Owner ormthodzed agent Date T ISSUED BY: —✓
OFFICE