25612 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL - ^ r /N re /�
DUILDING PROJECT IDENTIFICATION c 5 6 31.L
BUILDING
pADDRESS
/:��('/��/���) �(� SANITARY NO, APPUCATIONSUB/MIIITALDATE
oGo� ill LO/J&DOUN RD cuPEprWo UNIT# LOT# 03
OWNERS NAME It JOA �'�P1 �� CONTRACTOR'S NAME: LIC NO: N/C {l CONTROL#
•ARCHITEC'VENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
_ BL G ELECT PLUMB MECH
PERMIT ISSUANCE q El 1:1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ��-4VV10B DESCRIPTION
paZ Iherebyaffrm Hallam licensed underprovisioruofChapter9(commenciagwith
[u-1pp Section 7000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
N�1 kUgl
fall force and effece, 1-- - O
aR'y'y License Clens Lic.# UP TO 2M AMPS
ot Date Contractor 201-1000 AMPS
z8y4 ARCHITECT'SDECLARATION OVER I"AMPS SQ.FT.FLOOR AREA - $/SQ.Ff.
C Z'-'G I understand my plans shall he used as public records.
rr Y12�; SIGNS ELECTRICAL
941N 1 Licensed Professional
Q the OWNER-BUILDER DECLARATION CmuecTION SPECIAL CIRCUIT/MISC.
F. 1 hereby affirm that am exempt from Convmr's License Lew for the
3 m following reason.(Section 703L5,Business and Professions Cade:Any city or county TEMP.METER OR TLOST,
F ES y which requires n permit to construct,alter,improve,demolish,or repair any svucmre
}� prior to its issuance,also requires Ne applicant(orsuchpemtit to file a signed statement POWER DEVCE
Gp that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(commensing with Section 7000)of Division 3 offie Business and Professions Cade) SWIM L E IC VAJLUATISII�
or that he is exempuherefmm and the basis for me alleged exemption.Any violation of Q TLE - W CHES- S ��W
6 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
ore tM1an five hundreddollma($So0). NE TIAL ELE _
o axmUw1ofthepropeny,ormyemployeeswithwages eatheirsme<ompensation, Q - STORKS TYPE CONSTRUCTION
h dl do the work,and the motion,is not imendthliomfared for ash,(See 7044,Business B B
and Professions Cade:The Contractor's License Law does not apply to an owner of / o ,
property who builds or improves there.,and who does such work himselfor through his - 2 �t O ROUP RES.UNITS
wnemployees,providedthalsuchimpmvementsamn.tintnndedorofferedforsale.If, d
however,the building orimprovement is coldwithin one yearofcompletion,the.wner- TOTAL:
builder will have the harden of proving that he did not build or improve for purpose of
sale.). 4JA
Elm
I,as owneroffhe property,aexclusively c.mmeding with licensed contractors to QTY, PLUMBINGPtiERMI OD ZON APN
ts_
n.nuct the project(Sec.7044,Business and Professions Code:)The C.ntmcmrs PERMIT ISSUANCE
Lice nae Lawdoes such
pplymswhim .fpromms)whnsedPu orimpr.vhe Ciona,end
whence Lactsf.r such projectswitheconvacror(e)licensed pursuantmthe Con[mctora ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
License Lew. '
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner - Dam - RECEIPT,
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
-❑ Thereby affirm that lhave ecmificate of consent to self-insure,oracertifica[e of FIXTURES RECEIPTY
-PER TRAP _
' Workers'C.mpensmion Insurance or ecerfified copy thereof(Sec.3B00,Lab CJ which. PARK FEE Y N
covers all employee's anderthis permit GAS-EA.SYSTEM-1 INC,d OUT RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cornified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performareenf the work for which this permit is iwand,l shall .WATER HEATER W/VENT/ELECTR
not employ any person in any manner so ss to become subject to the Workers PAID
Comphrestionlawsof Califomia. Date WATER SYSTEMITREATING Data Receipt#
O 7-+ Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ,IT. TOTAL:
In become subject to the Workers Compensation provisions ofthe Labor Code,you must
•••"`���� forthwith comply with such provisions car this permit shall be deemN revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
•^� I hereby afftrm that there is a construction lending agency for the performance of TOTAL: ELECTRIC ME
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name
U _ PLUMBING FEE
Lender.Address QTY. MECHANICAL PERMIT PEE
U I ci nify that 1 have read this application and state that the above information is
correct.I agree to comply with all cit - MECHANICAL FEE
p city county ordinances and laws relating to PERMIT ISSUANCE
building construction,and hereby amhoriu representatives of this city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. '
(We)agree l0 snve,indemnify and keep harmless the City of Cupertino against
Imbililies,judgment.,costsmilexpenseswhichmay to.,way ace rue againnsaid City AIR HANDLING UNIT(TO I R"CFM)
in co uence of the gramin mf Ni0'
s ermit. .a
gf //rA.// ^� AIR HANDLING UNIT(OVER 10,000 CPM) -
Sig t roof Applicant/Contractor I/"7JDoleJ EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IGIM BTU) Date Reccipt#
Will the applicant or future building occupant store or handle hazardous materiel
as defined by the Cupertino Municipal Code,Chapter 9.12.and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTA
Coda Section e)7
11 Yet.
13 No
VENTILATION FAN(SINGLE REBID)
Yea
ISSUANCE DATE
Will the applicant arfuture building occupant use equipment or devices which emit BOILER-COMP(311P OR 100,000 BTU) ,
• hazardous air conwminanw as defined by the Bay Area Air Quality Management
Distract? ER BOILER-COMP(OV100,000 BTU)❑Ye. ❑No NEW RESIDENTIAL MECH. SQ.FT. p A Y D
I have read the hazord.us materials requirements under Chapter 6.95 of the
Cnlifomiallealth&Safety Code,Sections25505,25533and25534.I understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of - Ca
Occupancy. ,
Owner or authonzed agent Dare TOTAL: ISSUED BY:
OFFICE,