25050 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILUINU-KLEUDUCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25050
BUILDING PROJECT IDENTIFICATION
BUILDIN ADDS: I SANITARY NO. APPLICATION SUBMITTAL DATE
' = ` UNIT# LOT#
OWNSNSA E: � IP_O_E: cola
O IT 'S :e �� ^ �{IC NO: �� N/C CONTROL#
RCfIITGCT/RN (NEER: LIC NO: A 4' /Vn�l.-IJ(1 C ❑
J CONTACT: PHONE: QTY, ELECTRIC PERMIT" /VV FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
R88y� thereby affirm that l am licensed underprovisionsofChapter9(commencing with
Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
a F full force and effect. 4P
4 Zy,Uly f
License Class Lick UP TO 200 AMPS
y Z)ti Date Contractor. 201-1000 AMPS
ZOaiKARCHITECTS DECLARATION OVER IOWAMPS SQ.FT. OORAREA $/SQ.FT.
Z- I understand my plans shall be used as public records.
K 4�"q SIGNS ELECTRICAL
�Jq' Licensed Professional '
OWNER-BOILDERDECLARATION SPECIAL CIRCUIT/MI
qq�4H I hereby affirm tbar I am exempt from the Contractor's License Law for the
1 [!J C)w following reason.(Section 0031.5,Business and Professions Code:Any city or county TEMP.METER OR Po INS
Io" m.¢] which requires a permit to construct,aper,improve,demolish,or repair any strcmre
2 Q� prior to its issuance,also requires the applicant for such Permitto fllea signed satement POWER DEVICES +
Kuj p p Inst he is licensed pursuant toner provisions mflow Conu.....a License Law(Chapter
WWo 9(rommeocing with Section'/0)0)ofDlvlslon 3opha Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
iW M,,, or fiat he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-
4 Section 7031.5 by any applicont for a permit subjects the epplicanno a civil penalty of
not more than five hundred dollars(ESoo).
NEW RESIDENTIALELEC _SQ.FT.WwEI 1,mowneraftheroprty,ormyemploymswithwageastheirsolecompensation,
RIES TYPE CONSTRUCTION
S will do ms,imik,and the src Cibllsnctis License
La does a., (pl,to s4,Bus
and Professions Code:Tha Contractors License Lew does not apply io as owns is
propenywhous,ponorimprovesthuch improvndwhodcessuch work tandedimselfor through his OCC GROUP RES.UNITS
ownemployees,providr ithatimprovement
vement iss sold
within not earolfcomplfered torsade.If,
builder ,,the have
the
bur i en Uprooting
i that he within of build or improetif r I purpose
f TOTAL:
builder will hove the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,an,ownerof the propeny,em exclusivelyconuacting with licensed contractors to QTY. PLUMBING PERMIT PEE FLOOD ZONE AEN
construct the project(Seo.7044,Business and professions Code:)The Contractor's PERMIT ISSUANCE - U V
License Lawdoesnotapply roan ownerofpropen,who builds or improvesthereon,and
who contracts for such projects with a coatmctons)licensed pursuantm the Contractor's
License Law. ALTER (E )
FEE SUMMARY
❑ I sm exempt under Sce. ,B&P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I hereby affirm that l have a mi ifcate ofcoment to self-insure,or o certificam of FlKTIRiES-PER TRAP RECEIPT#
Workert Compensation lnsureacenr a cerifiedcapy thereof(See.3800,Lab C.)which x PARK PEE Y N
covers all employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
company
❑ Certified copy is hereby Famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthepemrit is for one hundred dollars($100) SEWER-SANITARY-STORM P.A.201FT. ENERGY FEE
odeaIc
Iceny that exon in ny,ma nthe work for whichesubject to the talshallkers' WATER HEATER W/VENT/ELECfR
not employ any person in sari.. Date so as to become subject to the Workers' ''�II PAID
z Compensation Lows of California. Dam WATER SYSTEM/I'REATING r (�V Deter Receipt#
Q O Applicant
V) NOTICE comesubject
APPLICANT:Work isIf,after Compensation
this Certificate of Labor Exemption,you,you should NEW RESIDENTIAL PCMB. SQ,FT. TOTAL:
rr become comply the Worker's Compensation p anis shallns be di Labor evoked. must BUILDING FEE '
forthwith comply with such provisions or this permit shall be deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC PEE
z
^a I 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.C.) TOTAL: 1,OP ELECTRIC PEE
Lki tr Lender's Nam. PLUMBING FEE
!-� Lenders Aaarexs QTY. MECHANICAL PERMIT FEE
0 V I carrythat I have read this application end sate that the above information ie
r�'t LSI correct l agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE MECHANICALFEE
hbuilding construction,and hereby authorizerepresentatives of this city to enter upon fie CONSTRUCTIONTAX
V 7 Whose-mentioneA property for inspection purposes. ALTER OR ADD TO MECH.
G' (We)ogre to save,indemnify and keep harmless the City of Cupertino against
liubilnie judgm Is,coals' enpcnseswhich meyinany way accrues ainsrsaid City AIR HANDLING UNIT(TO to,000 CFM)
I
thises,hil }
inconguenc -` AIR HANDLING UNIT(OVER 10,000 CFM)
/
Siglual of ApplicantlComramor Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Willthe applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(eJ7
13 Yes ❑No VENTILATION FAN(SINGLE REBID)
ISSUANCE DATE
Willtheeponterament,.defend by the
nBay equipmentQualitc Management BOILPR-COMP(3HP OR I00,OW BTU) PAID
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? I
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. MAY O ����
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat p'[fl 1"10if the building does nut comedy have a tenant,that it is my responsibility to notify the C iI UrSIU
occupant of the requirements which must be met prior to issuance of a Certificam of
Occupancy.
Owner or authorized agent Deter TOTAL: ISSUED BY. e
OF