25190 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILLHNU- .L- R AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25190
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING -1y, SANITARY NO. APPLICNIION SUBMITTALL7 DATE
7 C ` UNIT# LOT#
O ERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
reC� yf/k _ r / LI - NIC CONTROLN
I� ARCHI'11?CTryNGINEER: LIC NO: ADDRESSOh
CONTACT: PHONE: �Il+
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE IO F-1 F-1 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �A TOB DESCRIPTION
IOyMZ I hereby affirm Nat l am licensed under provision idChapter9(commrncingwith
,OE full force a0 Section nd eff�visinnJof the Business and Pmfessiom Code,and my license is in PANELS /M`77 l/,N
FQ„Zm License Class 14 List fU I ell D f UPTO2MAMPS T g /�
m7y Dam Comrvcnr 201.1000 AMPS
Z~MK ARCHITECTS DECLARATION OVER 1000AMPS SQ.1"II FLOOR AREA $/SQ.PP.
O Z—O 1 understand my pluns shall be used as public records. D S
\,
`W SIGNS ELECTRICAL '
�NL \\
< Licensed Professional U T�
o. OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
oi�dSOaF I herchy affirm mp
amt 1 am exempt from the Contractor's License Lew far the .K{
firlhoou13 B-ro which acquirmn.ermitIS01fort 101 IS,
toconstrut,Business and Professions Cale:Any lily otrcounty TEMP.METER OR POLE INST,
C LLits,y which requires a permit to construct,dor,improve,demolish,or repair any ansate
�yyi�F. Primnite issuem�c,alsorequircsthe applicantfor tech permit to fileasigned rtatement TOWER DEVICES
¢O that he is licensed pursuant to the Provisions of the Comment's License Law(Chapter
L o�' 9(commencing with Section70W)mf Division 7 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA N
y❑oo ar the,lm is caempuherefrom and the basis for thea leged exemption.Anyviolation of OUTLLTfS-SWITCHES-Fl%TUSES 0
�4 Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of /O�O 4
.Z.Z t mom than five hundred dollars($500). V
Kta�C� ❑ I,asownerofthepropmy,ormyemploymswithwagamtheirmlecamp .fi.., NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCfION
33— willdm the work.vWthenrucnm is not intendedoroffered formic(Sce.70,14,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work himself or through his
employces,provided that such improvements wenmimendedmoffered formic.if, OCC.GROUP RES.0 ITS
however.the building urimprovemrnt issold withinoneyearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purposeof
sale.).
El 1,asownerofthe powerty,amexclusively concreting with licensedcontmenrs n QTY. PLUMBING PERMIT FEE FLOOD ZONE ANN
construct the project(Sec.7044,Business and Professions Cala)The Contractors PERMIT ISSUANCE
License Luwdoes notapply tour ow.ermfproperty whobuildsorimproves thereon,and
who contmcts for such projects with a contnctims)Ilttmcd forward o the Contractors
License law. AIALTER-GRN&VENT-WATER(FA) FEE SUMMARY
❑ 1 em exempt mMer Tec. ,B&P C for Nis rtvson BACK FLOW PROTECT.DEVICE OUTSIDE FS
SANITARY Y N
Owner Date RECEIPTN
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby affirm thatlhaveecenificem of conumnulf-insum,orecertificvm of RECEIPTp
Workers Compensation Insurance or a certified copy thereof(Sm.3800,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
covers all employce s under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ CmifwI copy is filed with the city inspection division. GREAS&RNUUSTRL WASTE INTERCEPTOR GRADING FEB
CTRTIFlCATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need not be completed ifthe permit is for one hundred dollars fSIM) SEWER-SANITARY-STORM P.A.2WIT. ENERGY ME
m less.)
I certify that in the perfmrnanceofth workfor which this permit is issued,l shall WATER HEATER WIVEUDELECTR
not amp perm. n n become subject to Ne Workers PAID
Z Cmmpen I of iJ. o ss ^^� WATER SYSTEM/fREATBJG Date Receipt
0 NOTICE TO APPLICANT:If,oftar makings Certificateof Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. 'TOTAL:
t' In become subject m the Worker's Compensation provisions of the Labor Code,you all
7 forthwith comply with such provisions or this Permit shall be d revoked. BUILDING FEE �-
a [a CONSTRUCTION LENDING AGENCY SEISMIC PER
Z emby affirm that them is a construction lending agency for the performance of
,V O t ark for which this Permit is issued(Sec.J09],Civ.CJ TOTAL: ELECTRIC FEE
nders Nam.
OPLUMBING FEE
Lenders Address QTY. MECHANICAL PERMIT FEE
I certify that I have mad this application and sou that the above� information w. is MECHANICAL FEE" 0. cored.)agree to comply with all city and eounry ordinances end mase laws rchtingn PERMIT ISSUANCE
building construction,and hereby authmim mpmumatives ofthis city to enter upon the
U 7 above-mentioned property for inspection pufmus. ALTER OR ADD TO MECH. CONSTRUCTION TAX
C7 (We)agree to save,indemnify and keep hnmless the City of Cupertino against
Iiabilities,judgmemi.cmtsand expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,001)CFM)
in cone ¢of the tin Thispermif.
6iow AIR HANDLING UNIT(OVER l0,lI00CFM)
ignawre nr Applicam/ mInswo Dam EXHAUST HOOD(WMUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE y HEATING UNIT(TO I00,O00 BTU) Date Receipt#
Will the applicant or future building occupant ware or handle hazardovyrmeudal HEATING UNIT(OVER 100,0)0 BTU) TOTAL:
es defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)?
❑Yes ❑No M VEILA TION FAN(SINGLE RESID)
ISSUANCE DATE
WillthenpPliwnmr(marc builtlingoecupanmuequipmrntordevices whichemlt BOILER-COMP IMP OR IM."BTU) -
hazardous air communims as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER I00,OW BTU) all H
District? � n 1
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT, _40/ U0
I have read the hazardous materials requirements under Chapter 6.95 of the a.661 0 I
California Health A Safety Code,Sections 25505,25533 and 25534.1 understand that pp'
if the building does not currently have a tenant,Nat it is my responsibility to notify the .[/s�• i
occupant of the rcquircmenu which moat be ten prim to issuantt of a Cenifmme of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: