25948 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - L -ELECTRICAL PERMITNO.,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, n C(� /I O
BUILDING PROJECT' 4 o IDENTIFICATION L J J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
z DEP- �(
OW 5 E mss ' ONE:'as� CONT#ACf ' AME: �D���p v{._D�� N/C CONTROL#
RCHITECTIENGINEER: IrL,v4 LICNO: (/II DRE : SVOD JYJI'��'2 ❑
ONTACf: PHONE: 3
31� �5f QTY. ELELTRICPERMIT PEE
ILDINGPERMIT INFO
BLDG
El-ECT PLUMB
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vS D /, PERMIT ISSUANCE El
11 11
LI'ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL p�Cg��n
omz Ihereby affiwthat l an licensed under Provisions of Chapter 9 burrmencing with OBD
¢100_ Section"1000)ofDivism 3 of the Buainend�fessionsCWe,and my licenm is in PANELS �VLVI (I/�V L/F V w
KU full force mrd<f(cct. —/]I ,.1�
<z license I�s. Lic.# UP T02AOAMPS - DF 1`S VP
yQd Dmc Comrmin 301-1000 AMPS
FyZ RCHITECTSDEA RATION OVER TWO AMPS SQ,ff.FLOOR AREA SISQ.Pf.
0Z_ I understand my plans shall be used u public records.
rSIGNS ELECTRICAL
G1 Licensed Professional
SS OWNER-xeBUILDER DECLARATION SPECIAL CIRCUIT/MISC.
m
°�O V 1 hereby affirm that I aempt from the Contractor's License Law for Ne
y following umnn.(Section]031.5,Business and Profession Cade:My city or coumy TEMP.METER OR POLE INST.
ON construct.which requires a peN to cact,alcor,improve,demolish,or repair any structure, POWER DEVICES
}� on.,to its issuance,.jmou do,.theappliant forsoch permit file.signedsunment
41 a pursuant to that he is licensed pursto the provisions of the Contractors License law(Chapter
a�' 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC � VALUATIaON
Wyo urtlut he is exempt therefrom and the basis for the alleged exemption.Any violation of
ewi /-1
E Z.Q Section]031.5 by any applimatfar.ptsubpt,ts timit,licam to e civil pcnahOUTLETS-SWITCHES-FIXTURES 3sa (0O
y of
not mom than five handled dollars SSW).
W c ❑ I,asownerofthepropny,ormyemploymswiNwagesuthei...lammpemaion, NEW RMIDENTIALELECR _SQ.FT. STORIES TYPE CONS TRUCIION
willdo the work,and the swcwm is not intendedoro(faced for. e(Sm.7094,Business I
and Professions Code:The CmIrecon s License law don out apply to an owntt of
propcny who buildsorimprovesthereon,andwhod«ssuch work Nmselforthrough his OCC.GROUP RES.UNITS
own employees,provided Nat such i mprov emenu arc not intended or offend hassle.If,
however,no,building or improvement is sold within oneyemnfixmplmien,theowxr- TOTAL:
builder will huve the burden of proving that he did not build or improve for purpose of
le.). QTY, PLUMBING PERMIT FEE
E) Las owneroRhe property,em exdmivelycanwming with licemWconwnaeso MOOD ZONE APN
convect the project(Sec.]094,Business and Professions Cade:)The Contractor's PERMIT ISSUANCL
License Law does not.pplym an ownero(pofa,dy who builds orimproves thereon,and r
whocontracsforsuch projects with aconwctor(s)licensed pursuant lathe Contractors ALTER-DRAIN&VENT- ( FEESUMMARY
License Low.
❑ 1 con exempt under Sec. ,B&P C for this reason BACKFLAW PROTECT.DE g U NIGH ES
N
Y
Owner Date DRAINS-FLOOR.ROOF,AR ,C RECEIPT#
WORKMAN COMPENSATION DECLARATION S T Y_N
I hereby affirm that l have a certificate ofe neem to wit-hsau,or.certificate of FIXTURES-PER TRARECEIPT#
)OK,e, C.,n.,ioninsuraac �icacen'mdmpythvwgSaJgOQLab CJwhich DAT ARKFEE Y_N
covers all employee's undtt this pewit. 2 's 9 GAS-EA.SYSTEM-I ETI RECEIPT#
Policy# V J ILDING DIVISION FEES
Compvny GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cned copy is film
with the
Candiedcopy is Bled with the city inspection division. GRGSPJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
#bis section need not be completed ifthe permit is foronehundrcd dollars(SIM) SEWER-SANITARY-STORM EA.2W". ENERGY FEE
or less.)
I certify that in the Performance of the work for which this permit is issued,Isend WATER HEATER W/VEN1YELEA7R
not employ my person in my manner so as to become subject to the Workers - PAID
Compubmian Lawsof C.lifomia. Data WATER SYSTEM/TREATING Date Receipt#
O Z Applicant
z 0 NOTICE TO APPLICANT:If,efmr making this Ceribcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
r LO) become subject to the Workers Compensation provisionsab
of she labor Cale,you muse
LaII ' forthwith comply with such provisions aphis permit shall be deemed levoked. BUILDING FEE.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the performance of
V 0 the work for which thisTOTAL: ELECTRIC FEE
pewit is issued(Sas 3097,Civ.CJ
L4 lenders Name PLUMBING IEE
O F^ Lender.Address QTY. MECHANICAL PERMIT FEE
L! 1 certify that I have read this application and sum that the above information is MECHANICAL FEE
>" 0. cconcl Iagree,ommply with all city mddcounty radiant and sum laws mhting m PERMITISSUANCE
L^ building construction,and hereby aothonu mpresemm)ves afthis city la enter upon the CONSTRUCTION TA%
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
a (We)agree to save,indemnify and keep harmless the City of Cupenino against
liahilitio,judgmenu,cot,mrd expensax W,h may in my way accme.,am,,said City AIR HANDLING UNIT(TO 10."CPM)
i anseyu n oft granting Nis it.
Mr DIV VI MR HANDLING UNIT(OVER 10,000 CFM)
AA a
S Secure fApplic.nU mor Date EXHAUST HOOD(WIDUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Rwcipt#
Will the applicant os hi mm building occupant stare or handle hesitations metenel HEATING UNIT(OVER 100,000 BTU) T
n defined by the Cupertino Municipal Cade,Chapter,9.12,and the HeNth and Safety
Cade,Section 25532(aIyo VENTILATION PAN(SINGLE RESID)
❑Yes m
Willtbeapplicantffumrebuildingwcupmtu.eequipmentmdeviceswhichemit BOILER-COMP(3HPOR I00,ODOBTU) Y ]�S�IA�CE DA
intention.aif matmnmants as defuW by the Bay Afea An Quality Management BOILER-COMP(OVER 100,000 BTU) res 1 u
Imnm, ❑ RAR 291994
Yes �No NEW RESIDENTIAL.MECH. SQ.FT.
1 have read the hazafdous materials requirements under Chapter 6.95 of the CSI Y Vf V
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that Urr nj HvV
ifthe building does not currently have.mount.Net is is my responsibility to andfy the _ _
ont ccupaof the requi t which t be {t or to ai t'...of a C 'fie f
Occup.ncy. yrs yells N olq
Owner re hada agent, Data TOTAL: ISSUED BY:
OFFICE