25870 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELERICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 25870
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAnONSUBMDTALDATE
O D• /! UFRTIt LOTH
OWNERS NAME: PHONE CONTRACTOR'S NAME: LIC NO: NIC CONTROL
_ /✓� Aiv ✓ �Qi✓ t"/tf D/SY
4RC ITECr/ENGIN tR: LIC NO: ADDRESS: ❑ ��
I IcONTAcF�f: F 3b//��j`� 67C2 QTY. ELECTRIC PERMIT FEEBUILDING PERMIT INFO
BLDG ELECT PIj1f.IB MOI
a s i J /s' pJG 6 PERMIT ISSUANCE Iq r
Y�](
LICHNSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nmz I hereby effort Nat l am licensed underprovisiansof Chapter9(commencing with
u100 Section 701)(1)of Division 3 of the Business and Professions Cade,and my license is in PANELS
%� full Toros end effmt.� Up 70200 AMPS
6 y License 1 �J _Lie.N
ho<y Dme�Conwctor �Z'/'C 201.1000 AMPS RFMA'led �i"' .✓G
F'yZ ARCHITECTS DECL RATION SQ.FT.FLOOR AREA $/SQ.Fir.
DO,—
l undersand my plans shall be used as public on .
. OVER IINNIAMPS
SIGNS ELECTRICAL
� 2 Licensed Prid',Wcoul �y
uCu� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xdx OyV 1 hereby affirm that I mm exempt from the Continues License Law fm the
W 3 a vFi following reason(Section 7031.5,Business and Professions Cade:Any city mmumy TEMP.METER OR POLE INST.
t(:0<_1 which requires a permit to construct,alter,improve,demolish,or repair any structure
primor its issuance.mWopnous thcepphem,for such permit to fileasignedsuument POWER DEVICES
W(-100 that he is licensed pursuant to the provisions of the Caron s License Low(Chapter
a eR! 9fcommemcing with Section 7000)of Division 3 of the Business and Profeminms Code) SWIMMING POOL ELECTRIC
WMtn mthat he is exempt herefrom and the basis for the alleged exemption.Any violation of p7
(_yyi• Section 7031.5 by any applicant for a permit subject&the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
5 ¢ not more than five hundred dollars($500).
e�71 0 NEW RESIDENTIAL ELECT _SQ.FT. STORMS TYPE CONSTRUCTION
22 ❑ ataLisiow meal eprop�rty,ormyemployeeswi biegesasale(See.comperosiness
a3_, will dothesions Code:"a
Contm.iactot is Lndese La a doed s not
to'MaW
owner
of
end Professions Code:The Contractors License Law does oat apply m an owner of T
property wbobuilds orimpowea Nemon,andwhodosseuch workhrmadforthrough his _ !�•
employess,provided that mchimprovememsaenm intendedmufrered foraele.If. GN Ar a(iJr OCC GROUP RES.UNITS
h waved the buildingor improvement is sold within one year ofcampleion,theowner- t ,Jtavf TOTAL:
builder will have the burden of proving to he did not build or improve for purpose of J
sale.).
❑ 1,as owneroftbepropeny.amexclusively contracting with licensed contactors to QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct Ne project(Sec.7144,Basins and probations Code:)The Camranm'a / PERMIT ISSUANCE '
License Law does not apply man owner of progeny who buil ds m improves on
there ,end
whocmmsactsforsuch projects with acanuucmrEd licensed pursuenuathe Connector's ,y se Law.
LicenALTER-DRAIN&VENT-WATER(PA) �' FEE SUMMARY
O�
❑ l am exempt under Sea .R&P C for this reason out SIM FEES
BACK FLOW PROTECT.DEVICE.
SANITARY YN
Owner Data DRAINS-FLOORROOFAREACOND. RECEIPT#
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
t Ihereby affirm bre l have a ceni0cate of consent a self-insure,or a cudfa:ute ofRECEIPT#
Milk re'Compensaion lnsumnceorecenified copy Nerrof(Sec.JgW,Lab CJwhich FIXTURES-PER TRAP PARK FEE Y N
ra.II mnployee x underthii neon t. GAS-EA.SYSTEM-)INC.4 OUTLETS rik ECEIPT#
Policy# N61VISIONFFfS-
Company GAS-EA.SYSTEM-OV ER4(EA) pLANCHE
❑ Certified copy is hereby furnished.
Certified copy is fled with the city inspection division. GRHASPIINDUSTRLWASTE I E C[ 3 G
CERTIFICATE OF E%EMPION FROM WORKERS' GREASE TRAP I In
�'a �• SO 4
COMPENSATION INSURANCE
This section need not be completed Bum permit is for one hundred dollars($100) SEWER-SANITARY-ST NK .2� . 17ER 'H
or los.)
leertitytba in theperformanceofthe work firs hich thispermitis ismed,l shall WATER HEATER W/VRNT/ELECT
not employ any person in my manner so as to become subject to the Workers P ID
Compenmlonlawsof Celiforha. Date WATER SYSTENITTING D eipt#
0 Z Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. T r4
p•-1
rA become subject to the Workers Compensation provisions of the Labor Cade,you must
La' > forthwith comply with such provision or this permit shall be,deemed revoked. BUILDING FEE
Lid Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z1 hereby affirm that there is a concoction lending agency for the performance of
O the work far which this 1+e it yjssucu(sec.3097.Civ.C.) A ELECTRIC FEE
Lender's No..— NFFF
u" QTY. MECHANICAL PERMIT FEE PLUMBING ME
Leader's Address
U I terrify that I have need this application and stale that the above information is
correct.l agreed comply with all city and county dalliances and state laws relating to PERMITISSUA F. MECHANICAL ME
building construction,and hereby amhodx repnesinauves ofthis city mentor upon the
U z, above-mentioned progeny for inspection proposes. ALTER OR U TO MECH. CONSTRUCTION TA%
(We)dome to save,indemnify and keep hmmless the City of Cupertino again
linbililiee.judgmema.coat&and expense wlhchmay inanywayacemeagaiontsaid City AIR HANDLING UNIT(TO 10,000 CFM)
consequence of the granting of this permit.
t ATR HANDLING UNIT(OVER IO,IXIO CFM)
n �Or - e E%HAUSTHOOD(W/DUCD
Signets of APPlicw aha PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dau Receipt#
Will the applicant or name building occupanutoreor handle hnasrdaus mmerial HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Code,Sec0x)7
0 ye, ` No VENTILATION FAN(SINGLE RESID)
Yes ry
Will Neepplicentnrfuture buildingaccupant useequipmenmrdeviceswhichemit
BOILER-COMP(JHP OR 14.000 BTLI) ISSUANCE DATE
hazardous air connotations as defined by the Bay Asa Air Quality Management BOILER-COME(OVER 100,"BTU) pp��
Distad? 7y�� P A 1 pal
❑Yn r`a NEW RE$IDF.MTAL MECH. SQ.FT. p 6/
1 have read the havardous materials requirements under Chapter 6.95 of the aa1/{R
Culifomis Health&Safety Code,Sections 25505,M33 and 25534. 1 understood that (� A(I�
14
if the building does not currently have a tenant,that it is my responsibility to notify the 1Oa7
occupant of the require mems which must he met prior to issuance of a/C$�_ifmae of CII Y Uf
Occupancy
Offer nr am�ed agent a� TOTAL: ISSUED BY:
OFFICE