25916 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO H ILDI U-ELECTRICAL PERMI'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C(J
BUILDING PROJECT IDRKI'IFIC 105 JN G
16
BUILDINGADDRESS: ,/� SANITARY NO, APPLICATION SUBSUITAL DATE
lo,ii lJ/rf1/'C:l: UNIT# LOT 2—/ Lf
O NIiRS NAME: - PIIONE: CO RACIOR'S NAMI?: LIC NO: NIC CONTR LN
fY IK- Inro Lj n 9a-310 1• 0(f'���t�ti�o� 44 RCHI'fECT/LNGINEER: LIC NO: 'V 5g'4 S' a ilt Ver s
CON'I'ACI': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BCUG F.LECf PLUMB MCCH
PERMIT ISSUANCE fCy
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
�yz I hereby affirm that l em licensed under provisionsol'Chnpon9(cmmuencing with 00 Section 7")of Division 3 of the Business and Professions Cale.and my license is in PANELS
icaace aass reel
LUPT0200AMPS �!>
GLL LII force
effect.
Lio.# l
y6d Data Cmduca r 201-IBM AMPS
F't' Z ARCHITECTS DECLARATION SQ.FT. OUR EA S/SQ.PT.
ZOrn— Iunderstandm I hll be used public records. OVER 10100AMPS
O'G—G YPanss a
FNi�; SIGNS ELECTRICAL
� �� Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISE.
a.'Oa V 1 hereby affirm dust 1 wn exempt from the Contrecto's License law for the
sd3f-tFir following reason.(Section 7031q Business and Professions Co
Code:Any city or county TEMP.METER OR POLE INET.
�J aswhich requires u permit m construct,alter,improve,demolish,or repair any structure I�e
�a prinnoits issuance,also applicant ofileesi signed POWERDCVICf;S u�l
rcquim pp perm) gne I' �.
y1 0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aaot' 9(commencing with Section 7M0Iof Division 3 of the Business aro Professions Code) SWIMMING POOL ELECTRIC -, VALUATION
�r^y or that he is exempitherefrom and the basis for the alleged exemption.Any violation of OfTI FTS-SWITCHES-FIXTU
F Y Section 70315 by any applicant for a permit subjects the applicanuo a civil penalty of
A amore thanfivehundred Jnllmrs($500). NEW RESIDENTIAL ELCCTRSp�T'. l
W pce m❑ oche wrk,andepmpcny,ormyempleoroeragesrsudeiSec. 044,Bsiocu, ORIL.ti TYPECONSTRUCTION
a will Pr the work,and e:The Contractor's
not intended sicse Lae adl does not
apply to an Business
and property
whiom Code:The ve nthemar s License Law docs not apply to an an of
ownertywyces,pdsorimpmveschercprove who aressucherakhimffeandthrsale.Ie
OCC.GROUP RES.UNI"I'S
however,mees,pingor itumsuchent is sold
wi arenot earn complfered fatale.If,
however, l the burden of moving
dust
lie did art
eyem or improve
decanter. TOTAL:
builder will have the burden of proving Net he did not build or improve for puryose of
ale.).
❑ I,vs ownendlhepropeny,aro exdusivelywnuncting with licensed convectors to QTY. PLUMBING PhRMIT PEE PL00020NC AI'N
construct the pri(Sec.70,14,Business and Professions Code:)The Commuser'e PERMIT ISSUANCE ,D
License Law does not apply to an owner of property who builds or improves thereon,and
who comructs for such patients with a contranor(s)licensed Intonation m Ne Contractors
Licari Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DENIER lD d.l
SANITARY Y N
OwnerGOND
AREA
ROOF., . .Da¢ RECEIPT#
WORKMAN COMPENSATION OECUATI
RON DRAINS- SCHOOL TAX YN
ElThereby afllrm dM1mlhaveacenificam of cnnsenun self insure,nruartifcot<nf ww RECEIPT#
Watkins'Compensation Insurance ora certified!copy dureo'Sca.3800,Loh C.)which FIXTURES-PER TRAP •t' PARK FEB. Y N
covers all employees main-this pc.I,. It GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby bummed.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FXFMPGON FROM WORKERS' GREASE TRAP SOILS PER
COMPENSATION INSURANCE
('this section need not be completed ifthc permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
unless.)
T cenifydhot in the perfsmanttofdue work far which this permit is issued,I shall WATER HEATER W/VRN97ELECR
not employ any Person in any manner so as to become subject to the Workeri PAID
Cnmpemaa.am Luwxof Califnmin. Data WATER SYSTEMIGRATING Date Receipt Is
z Applicant
O NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLJdB, SQ.IT. TOTAL:
tZi become subject to she Workers Compensation provisions of the labor Code.you must
forthwith comply with such provisions aphisPenni d shall be banned revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY sat SEISMIC FEE
z I hereby affum that there is a construction lending agency for the Performance of TOTAL: —vI� ELECTRIC FEF.
J O the work for which this permit is issued(Sec.309],Civ.CJ
O E Lender's Name v PLUMBING FEE
Lender's Address Q'FY. MECIIANICAL PLRMI'1' FBE . n0
I certify Nm 1 have read this application and sate that the above information is MECHANICAL.FEE
correct.lagrce mcomplY'c'iN all city std coumy nrdiwnttaend stele laws rotating to PERMIT ISSUANCE
building construction,and hereby acNodm representation oflhiscity to enter upon the CONSTRUCTION TAX
V move-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m save,rude rd�and kap hamdess the City of Cupertino against
liabilhi ,jugmengcost dexp hichmayineny to,scameagaimtssm City AIR HANDLING UNIT(TO MON CIM)
u cc ofhe do P �p�t.
/1 AIR HANDLING UNIT(OVER 10,000 CIM)
�t� Y
Signmurc of App c tracmr - Delc PXHAUST IIOOD(W/DUC'q ��
PAI (�
I IA2ARDGUS MATERIALS DISCLOSURE HEATING UNITOO 100,000 BTLO Dam Receipt#
Will the applicant a(more building occupant store or handle havvdous material f�
as dclired by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10f1,11W BTU) TOTAL: ,( y
Code,Section 25532(q] V RNTUATION FAN(SINGLE RESID)
❑Yes ❑No
Will thcupplicvmorfmurc huildingoccupum useequipmemardevicee whichemil
BOILER-COMP(3HP OR lW,M0 BTU) ISSUANCE DATE
•hazardous air ronmmimarm;as defined by the Bay Area Air Quality Management ROILER-COMP(OVER I00,000 BTU)
Dist-ct]
❑Ye"� nm
❑Na NEW RESIDENTIAL MECfi. SQ.FT.
andInc haznrdous materials rcquiremnns under Chapter 6.95 of the FEB 41994
&Safety Coda.Sec' 25505,25533 mrd 25534.1 understand Not
sn currency arm that it is my responsibility m notify the �y�x
remenu cat et prior to issuance of a Certificatatee of `y11 YVf- Uf tnillVl)7 Nxca ager Date TOTAL: ISSUED
OFFICE