25998 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I CITY OF CUPERTINO JdILDI .-LLLC'TRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL f� C n n p
BUILDING DIVISION BUILDING PROJECI']DENTIFICATIO6 L J J J v
BUILDING ADDRESS: r SANITARY NO. APPLICATIONSUBMITTALDATE
u3 � 2 { 2� , L°InNhq SH�lr RAS �+ 9w
UNIT p LOT M
Oj1'NI Dry ME—W R� _ PHONE: CONTFA OR'SNAME: LIC NO:
L -C Iv-1H }� ,lNs/C CON'IROLN
ARCHITECT/ENGINEER: LIC NO:
ADDRESS: k'1 •G Q• S• '�S
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
—� BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El El 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ Ih700Fffnnth:nl Jidda
BmindcrprovisionwfCkptcr9(commencing wire a ^ JOB DESCRIPTION
t+J00 Seniace and
effect. on3nf the Rosiness end Profcsiuns Cnde,and my license is in PANELS
fall roree ane efrttt. - 112,/1
2, �1
FZ,L License Class Lic.N 1 �' a J UP T0200AMPS
o,cDale ` Conran,., 201-1000 AMPS
ZC00
ARCHITECTS DECLARATION OVER 100pAMP5 SQ.ET.FLOOR AREA S/SQ,FT.
O Z—O I understand on,plans shall be used as Public records. ., e ®
SIGNS ELECTRICAL \Vp
Licensed Professional
OWNER BUILDER DECLARATION SPECIAL CIRCUITWISC. , Ir �Tf'' r'^
XOaF 1 hereby affirm that 11an exempt from me Contractors License Law for the 9 , N �•".�
nl�Om followingreason(Seetion 7031.5,Business and Professions Cole:Any city or county TEMP.METER OR POLE,INST. VVV YYY 1'... j
which requires a permit no construct,alter,improve,demolish,or repair any structure
ecc,0-S prior m its issuance.also requires the applicant for such perminn file a signed statement POWER DEVICES TE
W C p LL 0z that he e l caned pursuant to the provisions of the Commit a License law(Chapter
1ip9(commencing with Section 700B,of Division 3 of the Business aSWIMMING POOL ELECTRIC
professions VALUATION
WM, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of �UTLEI'S-SWITCHES"FIXTURES
1_.Za Section 9031.5 by any applicant for a permit subjects Napplicant e applicano a civil penalty of
EEO nm mom than fee hundred dollars(SSW). NEW RESIDENTIAL F.LECfR
ce F_o ❑ Lasownerofineproperty.ormyemployeeswith wages as theirsolecompensation, SQ.FT. STORIES TYPI?CONSTRUCHON
y3e= will do the work,and the structure isnot inendedornffered for sale(See.70le,Business
and Professions Crate:The Commotion's License Law does not apply to an owner or
property whobuildsorimproves thereon,andwhodoessuch work himselfonhrough his
own employees,provided that such improvements aremt lmmmdcdmoffercd tarsale.If. OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yesfofcampletion,theowner- T
builder will have the burden of proving that he did not build or improve for purpou of
vale.).
❑ I,asowne of the progeny.amexclusivelycontmetingwimlicensed coneactorvm QTY. PLUMBING PERMIT FEE F71WDZONE ANN
ummact the project(Sec.7044.Business and Professions Code:)The Contn Wes
License law does not apply toanownerufpropenywho builds or impmves Hereon,and PERMIT ISSUANCE
who contracts forsuch projects with acontrac ma)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Scc. ,❑&PC for this rcawn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION TION DECLARATION SCHOOLTAX Y N
❑
Workers
Co affirm that Encave omium
cotepfconsenuossf(Sec.39 o,a ttnifwhi of
FIXTURES-PER TRAP RECF.IPI'p
Workers Cmployee.5nlerthis eorattnifiW copy mercog5s.38W,Lab C.)which PARKFEE Y N
coven all employee.5 under permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'p
Policy p
Company BUILDING DIVISION FEES
❑ Certified copy is hereby famished. GAS-FB.SYSTEM-OVF.R4TA) PLANCHF.CK FEF,
❑ Certified copy is fled with the city inspection division. USpSEONDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OI'EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
,\ (This section need not be completed ifine permit is forone hundred dollar,SI0B SEWER-SANITARY-STORM EA.200FT.
or less) ENERGY FEE
I certify the.inthe performance of the work for which mispermit is issucd,l shall WATER HEATER WIVENT/ELECIR
\ not employ any person to any rammer as to become subject to the Workers' PAID
Compensatmalu _ fCalif rrom Date so WATER SYSTEM/IREATING
Dom Receipt p
Q Z PPlicmt— i•ai�1 —
z0 NOTICET PPL A� l;after makig this Certificate of Emnapmm you should NEWRESIDENTIALPLMEL SQ.FT, TOTAL.
F In scans,subject 1. he Worker's Compensation pfovisions of the LabCW
h,Ce,you must
forthwith comply Mlh.such Pnwi.vimm or this pcccme
rmit,vhall be devoted rked.evo
7 BUILDING h13G
p, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm thin hem is a commuction lending agency for the performance of
U O the work for which this permit is issued(Sec.3W7,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I ccnify that I have read this application and state that the above information is
F1 correct.I ogee to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
V) building construction,and hereby authonu representatives ofthis city to enter upon the
U,,Z aMwe-mentiennd property for inspection purposes. ALTER OR ADD TO MF.CII. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liubilities,judgnmmx,conx and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO 10.0W CFM)
f the gmming�of�th.ais�permit.
//�� 9 AIR HANDLING UNIT(OVER I0.WOCFM)
Slg amen oenceolcanUComractor ' —� — 9 EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATERIALS handle
HEATING UNIT(TO IW,OW BTU) Dam - pts
Will the applicant aform bu
uildingoccupantstore or hazardousmammal
asdcfinedby the Cupertino Municipal Coec,Chapter 9.12,and the Heelm and Safety IILATING UNIT(OVER IW.(IW BTU) TOTAL:
Cade,Seaian 25532(u)?
❑Yes 0 N VENTILATION PAN(SINGLE RE510)
Will the applicamorfutumbuildingoampand useraptipment ordevices,which emit BOILER-COMP(3HPOR IW,0Oso ISSUANCE DATE
tomorrows air contaminants v defined by the Bay Acta Air Quality Management BOILER- ( 100,000 ' D
Distrix? COMP OVER BTU)
❑Ycs ❑No NEW RESIDENTIAL MECIT SQ.PT.
I have read the ha>abous--recall requirements under Chapter 6.95 of the AN z7 1994
Cvllfnmla Health&Safety Collor.Sections 25505,25533 and 25534. 1 understand that (�
if the building does not cuncally have a tenant,that it is my responsibility to notify the VI Y
oupanl of the requirements which mast he met Prior to issuance of a Cenificam of Ur (/urcri 1114
ccupancy.
Owneror audFn aagent Date
TOTAL: ISSUED BY:
OFFICE