25568 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL UIN.-ELECIKI AI. PERMIT NO.
APPLICATION/PERMIT PLUM ROJECTECHANIFI' 2 r r 6 E
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L 'V1 a�lJ YV�
HPI77 ADR7S: 'S/L� ���/ '] SANITARY NO. APPLICATION SUBMITTAL DATI
eA((VXVX�, SITif LOT#
O li N(.ytF ,/J AC �IONF.: CfyVTRpCTQR'SyYAM2;k /P_ ez l/ NO:
Ur'/ -lL_ CKJ�.J ,LIL..nJ�(_l/.`� .,/1t LL_Y/ N/C CONTROLp
ARCHI'JECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
q
-7 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
4'V
[
BLDG ELECT PLUMB p1CCH
PERMIT ISSUANCE ❑ ❑ ❑ I�TNys
LICENSED CON TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby of irm lh:n[.In licensed underpmvisionsol Chapter9(emamereing with JOB DESCRIPTION
VI C)2to
F. fullarIymd�,e' ym Urv'n eBusiness and Profesxions Code.unJ my license is in PANELS
f—NZI we
Dete� lassTECTS DECLA IOND3 / 2U TOAhMPs SRAREA S/SQ.F1'.
COOZ-0 IIuundeerrstanddd'my plaansss ssshha�ll�ll�lbe used as public recoNs. OVER IIXIO AMPS
SIGNS ELECTRICAL
Licensed Professional
CKec< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Fk Oy F I hereby affirm that I am exempt&am or'
the Comme a License Law far the
I¢1�Om followingaau
rcn.(Section 7031.5,Business and Professions Cure:Any city oreount, TEMP.METER OR POLE INST.
F"—y< m
which requires a permit ms construct,alter,improve,demolish,or repair any someone
KW};g prior to its issuance,alsorequires the applicant for such permit to file a signed statement POWER DEVICES
,=<o that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
9(mtmnenciag with Section 700o)of Division 3ofthe Business and Professions Cade) SWIMMING PO)LELE IC
a X a 11—is
oor VALUATION
W M,, or that he is exempt therefrom mad the basis for the alleged exemption.Any violation of OUTLETS - XTU FS
FZa Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of � r
Z not name than Be.hundred dollars(S500). 1
K F-o ❑ 1,asownernftM1cprnpcny.arm lu 0wa ma ae lhcirxolemm NEW RESIDENTIAL ELECTR S
yemp yeeswi b pensatinn. STORIES TYPECONSTRUCIION
y3e= will do the work,and the structure is not incendedornffercd for sale(Sec.70,L Business
and Professions Cade:The Conlrudor's License Law docs not apply to an owner of I
property who builds or improves thereon,andwbodoes.such work himselforthrough his was
eon employees,providedthal such impmveenemsart not imendedoroffered forsale.If. OCC GROUP RES.UNITS
however,the building or improvement is sold within on year ofoomple ion,the owner TOTAL:
builder will have the burden of proving that he did but build or improve for purpose of
sale).
❑ 1,asowneroflhepropeny,amexclusivelyconuactingwithlicensedmnt tomto QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.7000,Business and Professions Code:)The Commerce.
License Law docs not aPPIY lnanownttofpropery who builds or improves thereon,and PERMIT ISSUANCE
.ho umlmcls for such pmied.v with uemoullm(s)licensed pursuer,to IM1e Conlraelora
License Law. ALTER-DRAIN&VENT-WATER(BA) FEE SUMMARY
❑ 1 am exempt under Sec. ,p&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dale
WORKMAN COMPENSATION DECLARADRAINS-FLOOR,RUDE,AREA,COND. RECEIPT#
TION f C.)
SCHOOLTAX Y N
Wml
ElIhercby affirm thatlhaveacenifcate ofconsemto selLinsurc.oracb C.)w FIXTURES-PER TRAP RECEIPT#
rseall eons nsalionmumnu oratrenifier co_pyVltertoSu.�;A/Op,'Lab hieh ich PARKM Y N
PoI cyN !nI'p �q/5 (/ApCXI GAS-EA.SYSTEM-I INC.4OUTLFT5 RECEIPT#
Compwy BUILDING DIVISION FEES
:GR�SFM41SDUSIRL
SYSTEM OVER 4 BeA)
❑ Sr,ifeA copy is hereby furnished. FEE
Certified copy is fled with the city inspection division. WASTE INTERCEPTOR ECERTIFICATE OF EXEMPTION FROM WORKERS' RAP COMPENSATION INSURANCE,(TM1is section need mol be<ompleMifthe pemtit ix fm one hundreddollars(5100) ANITARY-STORM G.200FT. J�!ERGYor less.)Icenify lha,in IM1e perfonnaaceof the workforwhieh,hi,permit is issued,J,ImR EATERW/VENT/ELECTRnot employ any person in any manner so as to become subject,o,M1e Workeri z CompensaeonlawsofCulifrmia. Date YSTEMITREATING ate Rcceipl#
zNOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.ET. TOTAL:
I-^ y hat subject to the Workers Compensation provisions ofthe Labor Code,you must
7 forthwith comply with such provisions of this permit shall be deemed revoked. BUILDING FEE
per, CONSTRUCTION LENDING AGENCY SEISMIC FEE
:DZ I hereby affrn that hen is a construction lending agency for,he perfornana of
V O the work for which this Ism nil is issued(Sec.3197,Co.C.) TOTAL: ELRCU IC FEE
lender's Name
0 U Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I eerily that 1 have teed Ihis application and stale that the above information is
0. correct. I agree to comply with all city and county ordinances and state laws relating to
ISSUANCE MECHANICAL FEE
iia� building construction,and hereby authorize representatives ofthis city to enter upon the
U Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUC IONTAX
(We)agree m rave,indemnify and kap harmless the City of Cupertino agam.,
liibilities,jidgroam.cess andexpereswhich may in any waynanmagairn said City AIR HANDLING UNIT(TO 10,0do CIt)
in camcquence of the gon ing of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of AppllrnVCotnmcior Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Rescito p
Will the applicant or forum building occupant sore or handle hazardous material
de,Secth Cupertino Municipal Code,CTapter9.12,and the Health and Safety HEATING (OVER 100,000 BTU) A
C .
Cady Section 25532(a)?
C3 Yes C3 No VENTILATION FAN(SINGLE RPSID)
Will the aconta contaminants
as
by the ,use equipment Quality Management
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
�hmmdous air comaminants es dcfned by the Bay Area Air Quality Management
District? BOILER-COMP(OVER 100.000 BTU)
❑Yee ❑No NEW RESIDF.N'TIAL MECH. SQ.PT. P A 7 D
L
have mad the hazardous materials requirements under Chapter 6.95 of tac
ia Health&Safety Craft Sections 25505.25533 and 25534. 1 understand door ®��ilding d s rrently have a termthat it is m sporisibility m notify the 1(jt mems which mus,be met n of a C rdficate of X77ey. CII ma mizeda6enl Date
TOTAL: SUED BY:
OFFICE