25775 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nHlr.Dmf;-EI:ECTRTCA PF.RMI'TNO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDENTIFICATION
25775
IIfl1LU1NG 1'RO,IF:CI'IDN:NTIF'IC.A'fIf1N
BUILDING ADDRESS: SANITARY NO. 1 APPLICATION SUBMITTAL DATE
10379 ✓% A 4.410" 13iVOUNIT# LOT#
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
/194. �'AC.'l FrC�i7%nit, 73C-1,135THE LIelyEYIer oai ezT• (-L NI CONTROL#
•ARCHII'ECf/ENGINL'IeR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY, ELECTRIC PERMIT FBUILDING PERMIT INFOFEE
BLDG ELECT UM MECH
PERMIT ISSUANCE
LICI?NSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DGS IPf1
Matz Ihereby affirm Nm L azo licemed underPmvisionsofChapar9(corrtmencing with
5100_ OK
Section 700B.I'Divisimil.f Ne Business and Professions Code,and my If...is in PANELS
c�W full force and effect.
FZyUj License Class - -6 Lie.# 62o34L , UPTO200AMPS
co=FW Date Co DECLARATION T /dktlMA^}" OVERI0AMPS
zhOyZ ARCHITECTS DECLARATION OVER IOOOAMPS SQ. ARi E/SQ.IT.
1 undersand my plans shell he used us public mcords.
r y Ip:: SIGNS ELECTRICAL f1++��
Z,Jz Licensed professional yJ
6at� UWNI?R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. GG
UTER
O t1 F 1 hereby M.that I am exempt from the Commetols License Law for Ne
30 y fn0nwing Teas...(Section 7031.5,Business and Professions Code:A.,city or county TEMP.METER OR POLE INST. DAT
E5 ser which requires a permit to construct,alter,improve,demolish,or repair any structure
priormitsissuance,also requires the applicant forsuch permit to file asigned statement POWER DEVICES
at O that he is licensed pmrmsm to the provisions of the Cormacmts License Lew(Chane,
0--" 9Ricomencin with Section 7(100 of Division 3 ofthe Businessand professions Code SWIMMING POOL ELECTRIC
o�' gwi ) ) VALUATION
Orth7031. by rdo
mfromand the basPermit
subjects
Bar, -empion. civil
of OUTLET SWITCHES-FIXTURES
F- Q
Sectionrthan by anY applicant fon permit mbjaes the applicant a•civil Marshy of
not mom Than five hundred dollars($500).
NEW RESIDENTIAL ELECTR S .FT.
��t o ❑ Lasowncm(Neproperry,ormyempycmployeuwithweg-ustheirsolecompeaadon, —SQ.FT.
TYPE CONSTRUCTION
y"',3ro will do the work,and lhestructureis not intendedoro(fired forsale(Ses.7044,Business
and Profess ns Cade:The Comnctofs License I.ew does not apply to en owner of
property who buildsorimpmves Netmn,+nd whodaa such work hirttselforthroughhis
con employees,provided that such improvements moral intended proffered fonule.If, OCC.GROUP RES.UNITS
however.Ne building or improvement is sold within one year ofcompletion,the owner- TOTAL:
builder will have the harden of proving that he did not build or improve for purpose of
ls.).
❑ I,as ownerofthe property.+mexclusively contracting with licensed coatrectonto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
concoct the project(Sec.71,4,Business and Professions Cade:)The Continuities PERMIT ISSUANCE
License Law does not apply m an awm rof property who WJldmr improv-Hereon,and
whocnntmcts forsuch pmjects with a contnetoKs)licensed pursuant hills,Cmnrullm"
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT,DEVICIi SI ..S
5GRADINGFEE
TARY Y N
Owner Date DRAINS-FLOOR,ROOP,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION OOL TAX Y_N
• ❑ Thereby affirm that l have a cenificate ofcomenuo selfinsom,or cenificme of FIXTURES-Iff RECEIPT#
Workers Compermtian hoomacem.certified copy thereof(Sec.3800,Lab CJ wM1ich PER TRAP
covers all empioyeds under U)r ggomit. K FEE RECEIPT#—N—
Policy
Policy# "`a`C Z/0015,11 GAS-EA.SYSTEM-]INC.4 OUTLETSBUILDINGRFCFIION FEES
Company�V�e"A famished,
µ . GAS EA.SYSTEM-OVER 41EA) C14ECK FEE
❑ Ccnified copy is hereby famished.
la'CeriBed copy is filed wird the city inspection division. GRFASPJINDUSTRI.WASTI?INTERCEPMR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP S FEE
COMPENSATION INSURANCE
This section need not be completed ifthe Permit is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEB
or less.)
I cenify that in the performance of Ne wool,for which this permit is issued,Ishall WATER HEATER W/VENT/ELECIR
not employ any person in any dome,so as to became mbject to the Workers' PAID
Compensmion Luwsof Calif nsiA. Data WATER SYSTEMiTREATING
z A Date Receipt#
Applicant
z 0 NOTICE TO APPLICANT:If,alter making this Cetiricate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
L� V] become subject o the Worker's Compensation provisions of the Labor Code,you most
forthwith comply wiNsuch provisions or permit shall be darned revoked. BUILDING FEE
ped„ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
a z I hereby affirm that Nnre is a construction lending agency for the performance of T ELECTRIC FEE
O the work for which this Permit is issued(Sec.3097,Civ.C.)
IL P Lender's Nume
Lender's Address QTY. MECHANICAL PERMIT Flip, PLUMBING FEE
V 1 cenify that I have read this application and spite Nat the above information i4
correct.I apron to comply with all city and county ordinances d state laws relating to PERMIT ISSUANCE NCE MECHANICAL FEE
F' N building evormrmion,and herebyauthonm hipresenutivesofthisciry to cater upon the CONSTRUCTION TA%
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupeninn against
liubilitics,judgmema,cases and expenses which may in my way accrue spoon aid City AIR HANDLING UNIT(TO 10,IX0 CFM)
in conmyuence of the granting of this pernil.
AIR HANDLING UNrf(OVER 10,(1(10 CPM)
Signatureof ApplicanitConlrectoorrT�'•"` Date EXHAUST FOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building acupant store or handle h+aardous mutenal HEATING UNI'1'(OVER 1(10,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safely
Code,Section 25572(a)1
El Yes ❑No VENTILATION VAN(SINGLE RMID)
Will thea licantorfuturebuildin acu BOILER-COMP(7HV OR 100.000 RTU) ISSUANCE DATE
pp g panmseequipmcntordeviceewhichemit
haardous air comamirmat as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? ❑ A D
Yes ❑No NCW RISIDENTIAL MECFI. SQ.FT.
I have read the h.cardoas maerials requimmetns under Chapter 6.95 of the n/o�
California H-Ith&Safety Code,Sections 25505,25533 end 25574. 1 undersand /[I
that 199
Hthe building does not currently have a teem,that it is my rnFeasibility to notify the
occupant of the requirements which must be mel poor to issuance of a Cenificum of
Occupancy. 011 VI.
Owner or amhodmd ages, Dote 'TOTAL: ISSUED BY:
OFFICE---