25535 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIFC-RCECTRICA PERMITND'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANZIL
BUILDING PRODIC-FIDP.N'I IFICAI ION 5 5
J J
BUILDING ADDH SANITARY NO. APPLICATION SUBMfPI'AL DATE
t-tqRS NAM_I/` J U LOT# 7L(
OWNERS NAME: PHONE: COMI'RACTOR'S NAME: LIC NO:
' N/C CONTROL.p
ARCIII'I'ISC'I'/F.NOINEHN: LIC NO: ADDRESS: ❑ -
'ONfACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECU
PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
tyZ I hereby affirm that l am licensed underprovisions of Chapmr9(commencingwiN
00F+ Scction]OW)of DivisionJol the Business and Professions Cade,and my license is in PANELS ^.
In 11 three and effect. UP TO 200,AMPS
License�Cla�ss�/n � q
vFi6y
;k",
V4211 17—Cnntmcmr 201.1000 AMPS
ZOyZ, ARCHITECTSDECfARA N HCf,L_`�,r-J� OVER 1000AMPg SQ.FT.FLOOR AREA $/SQ.FT.
O Z to p 1 understand my plans shell be used as public records. ��22 "O
r n 1=m SIGNS ELECTRICAL
4 Licensed Rofessional /
�C,K OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xOa I hereby affirm that I am exempt from the Contractors License law for Ne
Is13aya fol lowing reason.(Section 7031.5,Business and Professions Code:Any city or count TEMP.METER OR POLE INST. r—� T
�J which requires a permit to commit,alter,improve,demolish,or repair any structure P Itll YR
)+ us its issuance,also resuims the applicant for such eco file a signed statement POWER DEVICES
prior I pp Penni gn
�Oilia,he is licensed pursuanno the provisions office Contractor's License Law(Chapter
9(connnencing with Sectitm]000)of Division3 of the Business and Profeseione Code) SWIMMING POOL ELECTRIC TION
or that he is exempt therefrom and the basis for the alleged exemplion.Any violation of
z,Q Section 7031.5 by anyappaicant far u Permit subjects the dpplicanno n civil penalty of OUTLETS-SWITCHES-FIXTURES
Y t more Nan five hundred dollua(Send.
W m n❑ I.asownemflhepml y.ormyemplowswiNwagaas Neirwlecomprnssfion, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPECONSTRUCIION
d3— will dothe wonk,and Nesbumum is nos imenddoroffered hostile(See.]044,Busmeia
and Professions Code:The Contractor's License Law does not apply to an owner of
property whoboildsom improvescameral,and whod.such work himsdfor through his OCC,GROUP RES.UNITS
wnemployees,provided that such improvememamenot intenddoroffeaA forsate.if,
however,the buildingarimproviment is said withinoneyemofcompletim,theowner A —�
builder will have the burden of proving that he did not build or improve for purpose of
.ale.)' QTY. PLUMBING PI7RMIT FEE FLOODZONI! APN
❑ Las nerofthepec.704A. usincvelyconmactingwirdde:)The
amswn the project(Sec.]044,Bmiofpi and Profesywho;ions orimp The Chemo ,and PERMIT ISSUANCE.
License Law ricesnot applyctanownerofpmperry whoseiIdsra improvhethereon,end
Lictmewho mctsforsuch pmjccuwiNemntmdor(s)Iiccnxdpunuennothc Convacwte ALTER-GRAIN&'VENT-WATER(FA) FC:ESUMMARY
License Lew.
❑ 1 em exempt under Sec. ,p&P C for this rtason ourldDETM
BACK FLOW PROTECT,DEVICE SANITARY Y N
Owner - Date DRAINS-Fl.00R,R(IOF,AREA,CON D. RECEIPTp
WORK MAN COMPENSATION DECIARA'I'ION . SCHOOLTAX Y N
❑ I hereby affirm that l have a cermicum ofcoment roselbinsum,ora vertifiwmof FIX'T'URES-PERTRAP RECInVf#
Workerd Compcnsetionlnsumncemocenified copy thereof(Sec.3Bg1.LnM1CJ which PARK FEC YN
covers all employee's under this permit. GAS-NA.SYSTEM-1 INC. DIITLET$ RECEIPT'#
PNicy p BUILDING DIVISION FEES 4
Carolina, GAS-CA.SYSTEM-OVER 4(EA) PLANCHECK FEC
❑ Certified copy is hereby famished.
❑ Cenifid copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Wine permit is foram hundred dollars IS 100) SEWER-SANITARY-STORM HA.200FT. ENERGY FEE
arless.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENTp?L13CfR
not employ any person in any manner so ex to become subject to the Workers' PAID
Compensation Lawsof Cdifomie, Dole WATER SYSTEM/IREA'FIND Date Receipt
Q Z Applicant
z0 NOTICHTO APPLICANT:If.after making this Certificate of Exempiian,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
�+ LI) become subject to the Workers Compensation pmvisimesof the labor Code,you must
a , forthwith comply,wird wch provision;or this permit shall he deemed revakul. BUILDING FEF,
LTa s-.
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that .it is a construction lending agency for the perfonnance of :
V O the work for which Nisis the permit is issued(Selending309],Civ.CJ TOTALELECTRIC FEE
LT. p-n Isndcrs Name r PLUMBING FEE[-' Lenders Address QTY. MECHANICALPERMIT FEE
V I cenify that I have mad this application and slam that the above information is
�"' 1 correct.ldgreeto comply with all cit and county ordimances and.,;laws madding to PERMITISSUANCE MECHANICAL FEE
huildingcommucdon,and herebyauthorice repreemafivesof Niscit to enter upon the CONSTRUCTIONTAX
U Z above-mentioned property y for inspection purposes. ALTOR ADD TO MECH.
(We)agree to save,indemnify and keep hasmleee the Cit of Cupertino against
Iiabilitiviijudgmencs.costs and expenses which may in any way areme against said Cit AIR IIANDLING UNIT GO 10,03)CFM)
ineonsequenceof Negnantin Johhis 't.
O
/sem '/D-�` AIR HANDLING UNIT(OVER 10,"CFM)
Signature of ApplicunNCOnwm
cr (�---_ 7 Dam S CXHAUS'1'HOOD(W/DUC'Fl
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00%)BTU) Date Receipt#
Will the applicant or future building occupant store or handle hurardous mater id
us defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER tM.000BTU) OTAL:
Cade.Section 25532(a)?
11 Yea ❑No VENTILATION FAN(SINGLE RPSID)
r
NOILER-COMP(3HP OR 100,00q BTU) ISSUANCE DATE
Will the epplicem ter fmurt building occupant use equipment nrdevicce which emit
"a to s air comaminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,CM BTU) -
Disria'f
❑Yes ❑Nn NEW RESIDENTIAL MECI I. SQ.FIL PAID D
I have mad,the hassrdoui amenielx rtquirtnnems under Chafer 6.95 of NP
e
Celif anis Health&Safely Codc,Sections 25505,25533 and 25534.1 undemmnd that ���
if he bulldog does dm curendy have auctions,Nm it is my responsibility m notify Ne ^-
mcupam of the requirements which must be met prior to issuance of a Cenif¢zte of Y
Occupancy.
Cr r
Owner
min mhndzul agent - Dem TOTAL: ISSUllBde
OFFICE