25512 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 2551
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: `I craw `I SANITARY NO. APPLICATION SUBMITTAL DATE
hI N/ 1 J1 I� � %V UNIT LOT# r
OWNERSNAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
�C gw a � ' s NIC CONTROL#
�ARCHITECT/ENGINEER: f LIC NO: IADORE
,i$&G mo J k2mI Y. El
CONTACT: PHONE:
QTY. ELECTRIC PEW FEE BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE (' � �M/^ � e/
LICENSED CONTRACTOR'S DECLARATIONpppLIANCES-R SIDE IAL JOB DESCRIPTION
09Z Ihereby affirm that lam licensed under provisions of Chapter 9(commencing with
POCI Section 7000)of Division 3 of rhe Business and Professions Code,and my license is in PANELS ��SuDpRT Q
yy� full force and effect UP TO 205 A PS Cr_1 I aL i7
F2�v License s Caarum�
m D N Date FECTS D 201-1000 P
Z8.4 ARCHITECTS DECLARATION OV MPS Q�FT
O Z—G I understand my plans shall be used as public records. /� p
Pr� a - - SIO CTRICAL t TO CI"�/.1 11 U
Q' Licensed Professional 7 TT R
ff 6 OWNER-BUILDER DECLARATION I E IAL CIRCUI g Liv
PUS, Ihereby uffirn that 1 em exempt from the Contmctora License Law' the Y�
r�3 m following reason.(Section 7031.5,Business and Professions Cade:Any city or toeinty MP.M R E ST. DATE
�FF�yy m; which requires a pemti.to comswm,alter.improve,demolish,or repair any structure
�j J+� priorte its issuance,also requires the applicant for such permit file aligned statement POWE I S
OK that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a oLL 9(commencingwith Section70W)of Division3ofthe Business and Professions Code) SWIMMI POOL ELECTRIC VALUATION
y' ,y or that he is exempt therefrom and the basis forthe alleged exemption.Any viol.ion of OUTLET, SWITCHES-FlXTURES
ZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of a .w
not more than Five hundred doll.,($500).
^o ❑ Ts wneroftheproperty,ormyempleyeeswithwagesastheirsolee mpensation, NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,and the structure is not intended or offered for sale(See70bL Business ' ,1n..W+ " V u gvyR
and Professions Code:Thm
Fire Comctors License Law does not apply.an owner of Y l.V
property whubuildsorimproves thereon,and whndaes such workhimselfordrough his OCC.GROUP RES.UNITS
own employees,provi dad fiat such i mprovements are not i mended or offered tar sale.If,
however,the building or improvement is sold withinone yearofeompletior,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Lasowaerofthe property,amexebsivelyaontracting with licensed contactorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7094,Business and Professions Code)The Coetr..rs PERMIT ISSUANCE /s
License Law does cmapply oanownerit property who builds or improves Hereon,and
who contmctsfor such projects with acono-actods)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) / FEE SUMMARY
%❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE SANITARY YFEES
N
Owner Dete DRECEIPT#
RAINS-MOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX YN
❑ Ihereby affirm
on Ins ranceve a ortificateof consyourrof(See.380 LabCcertificate whirb FIXTURES-PER TRAP / RECEIPT#
Workers'Compensetionlnsurance oreceri0ed copy thereof(Sec.3800,Lab CJwhich PARK FEE YN
covers,all employee's under thisrmit RECEIPT#
a GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy# BUILDING DIVISION FEES
Company VGAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ C rdfied copy is hereby famished.
l,
eni0ed copy is Filed with the city,inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need calls,completed iflhe femur is foroaehundred dollars P$100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER HEATER WIVENT/ELECTR
not employ any permit in any manner so as to become subject to the Workers' PAID
Compensation Lawson Califomia. Date WATER SYSTEWIREATING Date Receipt#
Z Applicant
Oz Q NOTTCE TO APPLICANT:If.ager making this Certificate of ExemNEW RESIDENTIAL PLMEL ption,you should SQFT. TOTAL: .
t•-I p] become subject.,he Workers Compensation provisimta ofine Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMICHIR
Z I hereby affirm that there is a construction lending agency for the Performance of ELECTRIC FEE
V O the work for which this permit is issued(Sec.3097.Civ.C.)
(Z. Lender's Name I PLUMBING FEE
header Address QTY. MECHANICAL PERMIT FEE
0 LUkI1 certify that I have read this application and state that the above information is / MECHANICAL FEE
correct.I agree to comply with all city and many ordinances and state laws relating to PERMIT ISSUANCE
rA
V buildingcorrametion,and hereby authorize representatives ofthis city to enterupon the CONSTRUCTION TAX
above-memioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree.save,indemnify and keep harmless the City of Cupertino against
Iiabilioc,judgmems,costs addexperows which may in any way accrue against said City AIR HANDLING UNIT LIG IBM CFM)
consequence q lh of th' permit, a.a AIR HANDLING UNIT(OVER 10,000 CFM)
Sigma
a.of Applicac Con .r Date EXHAUST HOOD DVMUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building cecupant some or handle hazardous around - T L:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,050 BTU)
Code,Semi 0Yee 25532(,)1
❑ —�# VENTILATION FAN(SINGLE RESID)
H N
ISSUANCE
Will the a licamorfmore boldin telae ti tordevices which emit BOILER-COMP(3HPOR IIo,050 BTU)
PP gay the q Amen ry
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 105,000 BTU) Y A ! 1)
District?
❑Yes Na NEW RESIDENTIAL MECH. SQ.FT,
I have read the hazardous materials requlremems ander Chapter 6.95 of the SEP - 21993
Califomia Health&Safety Cade,Sections 25505,25533 and 25534. T understand that
if the building does not currently have a tenant,that it is my responsibility.notify the /^�}}r
occupant of the reqummon s which must be met prior o issuance of a Ceniflcate of 4'1 1 Vt- vialmn a
Occupancy, m -
Owner or authorized agent Date ISSUED BY:
OF