25327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO »BSG-FLFC I RI . PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHA=11, 2 5 3 2 7
BUILDING PROJECT'IDENI'IF'ICA]'ION J
BUILDING ADDRESS: SANITARY NO. AFFLIC`ATIONSUBMfITALDATE
AMVUYIT# LOT# 1 `�1�
OWNERSN E: PHON CO CI' NAME: N/C L CONTROL#
�4RCHITECTIENGINEER LIC NO: ' ADD S. ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT ''PEE BUILDING PERMIT[NFO
4130 ELECT PLUMB MP.CH
PERMIT ISSUANCE �� ❑ ❑
Eldon ImD CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB S WUON
WOO Iherebyaf premium
Bu inssadd irolesa es Coulr9(commencing with
WOO_ Sectionome and e f Div' S of the Business and Professio Code,and my license is in PANELS
Cal 1-. full force mdeffea.151O" 9390359 IIP T0200 AMPS
FZ� License Class Lic.p
H Q a One Contractor 201-1000 AMPS
F-y Z, ARCHITECTS DECLARATION —SQ.-FT-hLOOH-ARE�A� $/SQ.FT.
FOO rn ]understand my plans shall be used as public records. OVER 1000 AMPS r
'L—� SIGNS ELECTRICAL
Q W W< Licensed Nofcssional
de�p2, OWNER BUILDER DECLARATION - SPECIAL CIRCUIT/IWSC. /IJJJ7
kO a tJ I hereby affirm that 1 am exempt from the Contractors License law for the '._,✓ v
m 3ER
0ce following mas°v.(Storem 7031.5,Business and Profession Code:Any city m county TEMP.METER OR POLE INST.
F a�; which requires a permit to construct.alter,improve.demolish,or repair any structure — J
�WY2 priorm its issuance,also requires me applicant for such permit to file a signed statement POWER DEVICES DATE
m W p O that he is licensed pursuant o the provisions of the Contractors License Law(Chapter _
dXo� 9(cnmmencing with Section 9II00)of Division3of,he Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-pIXTURFS
Z Q Sect ton 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(S500).
0: C] 1,asowncrofthepropeny,°rmyemployeeswith wages as theirsolecom NEW RESIDENTIAL ELECTR —SQ.pensation, Q TORIFS TYPE CONSTRUCTION
a3— will do thework,and due structure isnot intended oroffered for sale(Sec.?044,Business �aS�h
and Professions Cade:The C°menm tor's License Law docs not apply an owner,of
pmpcny who builds or improves thereon,and who does such work himself°r through his c- OCC GROUP RFS.UNITS
own employees,provided that such improvements artnot intendedoroffesc lfor sale.If,
however,the building orimprovement is sold within one yearofeempletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
salt.). Q'pY. PLUMBING PERMIT FEE FLOOD ZONE APN
iumseconstruct the project(Sec.to
Business and Professions Cade:)The Contractor's
License Lawdcesn°tapply to un ownerofpropeny who builds
orimproves thereon.unJ PERMIT ISSUANCE.
who contmcesforsuch projects with scontractogs)licensed pursuam ter the Contractor's ALTER-DRAIN&VENT-WATER G
liaruc taw. I > FEE SUMMARY
❑ 1 am exempt under Ss. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY SN
Owner Date RECPT#
DRAINS-FLUOR.ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihereby affionthat lhave c erm.sen,eed cop the..f(Sosum,0r Lm
CJwreoC FIXTURP,S-PIiR TRAP RECEIPT'#
�Wakems'C°mpense,ion lnsunmmmncertiCmd copy thereof(Sea 3800.Leb CJ which PARK PEE. � Y N
coven dlemploy 's 'f GAS-EA.SYSTEM-1 INC.4 OUTLETS RE
Policy N BUILDING DIVISION FEES
CompanyGAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hemby fumished.
❑ Canlfied copy is That with thecity inspection division. GREASFpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.2001if. VNERGY PEE
s less.)
I certify mat in me perfmmanceofthe work for which this permit is issued,Ishan - WATER HEATBR W/VENT/ELECTR _
not employ any person in any muter so is to become subject to me Workers PAID
z Compensationlawsof Caifomia. Date WATER SYSTEMiTREAsTING Date Receipt re
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTA
.�-i become subjauothe Workers Compensation provisions of the labor Code,you must
> fonM1with comply with such provisions or this permit shall be ducted revoked. BUILDING FEE
4 �] CONST RUCTION LENDING AGENCY SHISMICFEE
Uz 1 hereby affirm that mere is a construction lending agency for the performance of TOTAL Ii1.F.CTRIC FEE
O the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name
C) F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 ttnify that I have reed this application and stale that me above information is MECHANICAL FEE
curved. gena,o comply with all city seal county ordinances and smte laws mtatingm PERMIT ISSUANCE
F" Cg) building construction,and hereby authorizeremormentives of s 'rymenteruponthe CONSTRUCTION TAX
U Z "Mwe mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)'mem save,indemnify cop harmesa a C' of Cupertin/idg ,
liahili,ics,judgmens.ants unJ expo a hichmayin y engines, AIR HANDLING UNIT(TO 10,000 CFM)
a oRhe gr
AIR HANDLING UNIT(OVER 10,000 CFM)
Signatureof Applican n n r ate EXHAUST HOOD(W/DUCT) PAID
III AZARDOUSMA R IS CLOSURE HEATING UNIT(TO 100,000 BTU)
Date Receipt Jr
Will the applicant orfutummilJ' g cups .tore or handle hazardous material HEATING UNIT(OVER 100,00)BTU) TOTAL:
as defined by the Ce firm Municip e,C ter 912,and the Health and Safety
Cada,Sectio" x)2
11 Yes
El No
VENTILATION DAN(SING LE RESID)
Ycs
ISSUANCE DATE
Will the applicmtor future building occupant uscequipmentordevices which emit BOILER-COMP OHPOR 100,000 BTU) P AID
�hazallous air contaminants as defined by me Bay Area Air Quality Management BOILER-COMP(OVER IM.000 RTU)
Domain?
❑Yes ❑No NEW RESIDENTIAL MECO—SQ.FT. p1 .I 5 1993
1 have mad the hazardous materials requirements under Chapter 6.95 of the NOV 1 J
Culifnmla Health&S"rcty Code,Sections 25505,25533 and 25534. 1 undersmnd,hm
thine building does not currently have atenant.that it is my responsibility In until,the fr1 i� yr
occupied of the requirements which must be me,prior to issuance of a Certificate of V
Occupancy.
Owner or authorized agent Date TOTAL: ISSUEDB .