25682 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO x IL1 .-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 25682
Ii1111.DING PR11jEcT IBEN'11111CATION
BUILDING ADDRESS: l SANITARY NO. AWWCATIOSUBMITTAL DATE
O ' mO Al/ e J UNIT LOT# /o—ZOSN�X51 T
OWN17RS NAME: PHONE: CONTRACTOII'S NAME.: A )' N/C CONTROL#
0. HITECf GINEFR: LIC NO: ADDRISS: ❑
d, box 3 2 sv,eA .v
CONTACT: PHONE: o BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
gf
��\\ BLDG ELECT PLUMB MECII
e 907 V
D/ PERMIT ISSUANCE 0 ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
KZ I hereby affirm Nm l am licensed underpmonionsofatimar9(cmmmencing with /- ' A
00 Section 9000)ofDivision3ofibeBaroness mid Pmfesaaend
iocCodmylicenseisin PANELS hD ✓LI'zOh/H 2 e I
tt�Z full force end effgqt. /
F , License Clan C—3b Lic.M 1 201-I 0 MPS
MPS v-4k
LD L�•L
m7y Data /0_> _Conlamm 201-1000 AMPS Th PP
ZQ N7-y ARCHITECTS DE RATI iN OVER 11)(10 AMPS SQ.FT.FLOOR AREA g/SQ.FT.
O Z—IfIs� 1 understand my plans shall be used as pu lic records.
Fit j Licensed Professional
SIGNS ELECTRICAL
yv OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC,
xy O0.F 1 hereby affirm that I am exempt from the Contractors License Law for the
tvl a rn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which rcquiresa permit to canvrun,alter,improve.demolish.�Asee rqq�Py�mcturc DEVI
� Y� pnono iu issuance.also requirts Ne ea ar,mprove,h pemtiladfbn gnidls m t
cull cep O that he is licensed punvant m the pmvninns of the Convectole11l.am.L. (Chi
9(mmmencing with Section 7000)of Division 3 ofthe Busines and Pro'asiore Code) n sw MING BCTRIC VALUATION
W_rn m that he is exempt therefrom and he basis fon he all,ged,m;Iion.AnyvmImmi df S SWI FIXTURES
��sf7I P
p. Q Section 707 IS by my applicant for a permit subjects the applicant to e civil pendtyof 1 ,700-7 O D n/
nm more tMn five hundred dollen(5500). LELECfR _SQ,FT. STORIES TYPF.CONSTRUCHON
❑$ce ❑ Luownrk,andep Stora arm of intuyxswiffia ssasthe0pmI(p ma
will Pr NewonsCm: stearalsnot is License awdc forsalepplyto
and pouemfcssions Code:The Contractor's License Law does not ripply tom owner of
ownerywhob,pmvids impretsu NempmvannN=noho doas, tinch wnk roffeonhroaghhis OCC.GROUP RES.UNITS
own cmplmyces,prov idd that such i mprovetncnn art not i mm�dN m offered for sole.If,
however,the buildingor improvement is sold withinoneyearofcompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[I Lar owecrofihepropeny.amexclusively convening with licensed contnct.m QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
constmcl the pri(Sm.70sPL Business and Professions Code:)The Contractors PERMITISSUANCE
Lice nse law dms nm apply m an owmr of propery w ho bu ilds m improves Nemm,and
whocmnracts forsuch projects with a conoactor(s)licensed pursuant to the Contactors
Licrnso Law. ALTER-DRAIN&VENT-WATER([A) FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for this mtoon BACK FLOW PROTECT.DEVICE SANITARY out Y N
Owner Dam DRAINS-FLOORROOFAREA,CONDRECEIPT#
, ,
WORKMAN COMPENSATION DECLARATION . SCHOOLTAX YN
❑ Thereby affirm Nmlhaveacenificmc of cons enlmself-mmoc'oracenificateof FIXTURES-PER TRAP RP.CF.IPTY
Workers'Compensatinn Imuthm1n`ce ora certified copy thereof(Sm 3800,Lab C.)whichlb — PARK FEE Y N
PolicytiI�'l` - d b i��it. R[CEIPTp
GAS-EA.SYSTEM-1 MC.4 OUTLETS
BUILDING DIVISION FEES
Company r �^
❑ Certified copy is hereby furnished, GAS-EA.SYSTEM-OVER 4 HIA) PLANCHECK MR
EI Cenifmd copy is filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EKEMPION FROM WORKERS OREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is for one hundred dollars(S100) SEWER-SANITARY-STORM EA.20017T. ENERGY ME
or less.)
I cenify that in the perfornmce of Ne work for which this permit is issuW,l shall WATER HEATER W/VEN'OHLECIR
not employ any person in any mama sou to become subject to the Workers' PAID
Compcnsationlawsof Celifomia. Date WATER SYSTF.MITREATING Date Receipt Is
Z Applicant
C NOTICL10 APPLICANT:If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT.
TOTAL:
p-1 > become subjectaply it Worsuch Pr Campenndon Permit shall
labor Cooked. must
�i � forthwith comply with such provisions or this permit shell be dttmed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z l hereby affirm that there is a construction lending agency for the performance of
C the work far which this permir is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Ill.0 5 Lenders Name
finders Address QTY. MECHANICAL PERMIT FEF. PLUMBING FEE
V 1 certify Net 1 have read this application end etam that the eMve information is
corms. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
aw
rA building construction,and hereby aulhoriaempresemativee of0dsciry to enter upon the CONSTRUCTION TAX
U z above-mentioned property for ivpcetim purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in my way aceme against mid City AIR HANDLING UNIT(TO 10,"CFM)
in mrsoc,com of the grafi ofthis permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
ntoofAp„C, m�> vDy
Sign reofA IicanUCmtncmr m EXHAUST HOOU(W/DUCI')
PAID
HAZARDOUS MATERIALS DISCLOSURE HBATMG UNIT(TO IfID,"BTU) Data Receipt#
Will Ne applicant or future building occupant store or handle hazardous notarial HEATING UNIT(OVER 100,0(10 BTU) A
as defied by the Cupmino MmidMI Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)?
❑Ya ❑No VENTILATION FAN(SINGLE RESID) Q
BOILER-COMP OUP OR 100,000 BTU) ISSUANCE DATE
Will the applicant orfmurebuilding by
nBay A Air Quality
er Management OCT ��
. huallous wr mntaminmts os defined by the Bey Ana Air Queliry Managemm�t BOILER-COMP(OVER 100,0(10 BTU) 199
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have teed the hazardous madness 5505,lI5 33 under Chapter understand
of the
GIIY Ur CUPthunU
if
uil ingHealth&dos Safety Code.Sections 25505,25573 and 8534.I undersand Net
if the building does not currently have a moat,that it is to ounce of a e notify the
occuWm of the rcquiremenn which must be ma prior to issuance of a Certificate of
Occupancy.
Owner car endured agent Dam TOTAL: ISSUED BY:
OFFICE