25189 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO
PLUMBING- N
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECTr IDENTIFICATION
IIrICICATION 518 C
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
I .?Q C UNIT# LOT#
✓WNERS NA PHONE: C
ONTRACTOR'S NAME: LIC NO:
Q d r /� a R,1 1 y 1a. O �t 1�3 q NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
/S:: C�
CONTACT: PHONE:
>k _BUILDING PERMIT INFO.
Q d CPERMI :..
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 0 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �P TOB DESCRIPTION
0 y.Z I herebv affatm that I am licensed under provisions of Chapter 9(commencing with
iCO O Section 7000)of Division 3 of the Business and Professions Code,and my license is ci PANELS /-
-U 01
t full force and effe t. (/_^ ��`/ ,y`
E<-Z ty License Class Lic.# �77-3 UP TO 200 AMPS
to< Date Contractor 201-1000 AMPS
O Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
I understand my plans shall be used as public records.
"I-ul SIGNS ELECTRICAL n
Licensed Professional e�
w a< OWNER-BUILDER DECLARATION SPECIAL CIRCUrrfl HSC. _
O y U I hereby affirm that I am exempt from the Contractor's License Law for the
O IR
¢ following reason.(Section 7031.5,Business and Professions Code:Any city or county III".METER OR POLE INST. �; J
").J< which requires a pemtit to construct,alter,improve,demolish,or repair any structure
GLtl} prior m its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICFS
C4<p that he is licensed pursuant to the provisions of the Contractees License Law(Chapter
dp 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) SWIMMING POOL 11 ECfRI UATION
^y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of /. O CJ
Y Section 7031.5 b an applicant for t subjects the applicant to a civil of OUTLETS-SWITCHES-FIXTURES 400
D�o
F Z< Y Y PP� Pew j aPP� penalty
z O not mote than five hundred dollars($500).
❑ [,as ownerofthe property,ormy employees with wages as their solecompensation, NEW RFSIDENTIALE[.ECIR SQ.FT. STORIES TYPECONSTRUCTIOt
a 3 will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered forsale.If. OCC.GROUP RES.UNITS
however,die building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). k
[II,as owner of the property,am exclusively contracting with licensed contractors to FLOOD APN
construct the project(Sec.7044,Business and Professions Code:)The Contractors
License Law does not apply to an ownerof property who builds or improves thereat,and pERMIT ISSUANCE
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA)
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE UTSIDE1`EES
SANITARY Y N
Owns Ihue DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that I have a certificate of consent to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DMSION FEES
Company GAS-EA SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection divisioa GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any person in arty so as to become subject to the Workers' PAID
Z tAihcq.,_-,
ws of Califag �� 1 WATER SYSTEM/IRFATING Date Receipt#
7 CE TO APPLICANT:If,afar malting this Cermficate ofExemption NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:V) a subject to the Workers Compensation provision of the Labor Code,you must> ith comply with such provisions orlhis permit shall be deemed revoked BUILDING FEE �+
A CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that these is a construction lending agency for cite performance of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
r Lender's Name
I t-
Lender's Address PLUMBING FEE
m U I certify that I have read this application and state that the above information is e' '"
.. LTJ MECHANICAL FEE
. correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
I7
y t) building construction,and hereby authorize representatives of this city to enter upon the
Z above-mentioned for inspection ALTER OR ADD TO MECIL CONSTRUCTION TAX
ProPe�' �ti Pte•
-- (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs anxpenses which may in LIFM)
any way accrue against said City AIR HANDLING UNIT(TO 10,000 C
sequence of the gran- g f this mtit
AIR HANDLING UNIT(OVER 10,000 CFM)
pplicam/Contractor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
rebuildingoccupantuseequipmentordeviceswhichemit
hazardousBOILER-COMP(3HP OR 100,000 BTU) �($Sj�4IfDATE
Willtheapplicantorfutuair contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) /'1 �J
District? JUN 10
_ ❑Yes ❑No NEW RESIDENTIAL MESH. SQ.FT. 1993
I have read the hazardous materials requirements under Chapter 6.95 of the 111 r Ur
California Health&Safety Code.Sections 25505,25533 and 25534.1 understand that V (iUrtn 1 I1VU
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
Occupancy.
Owner or authonzed agent Date TOTAL: ISSUED BY: