25268 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDI G-ELECTRICAL PERMITNO.
SOBUILDIIVIN APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 25268 CZVH
BUILDING 9DWESS: SANITARY NO. AAPPA'DITI
IPLICONSUBM 'ALDATE
UNIT# LOT# 1_r
OWN' ����\ ' PHONE: CONTRACfO$SJJAMb`y _n',6A LICNO: �9
�V xa#iLr r.'�fL/f—1 NIC CONTROL#
CHITE GINE LIC NO: AD FSS: V sI
2ot54ik�wAY�'tACE �
COWACT: PHONE
MMI/) 15.' 1 { 1 jo" r.440,$)4 QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
1/n• l-� 1V^NJ���✓ BLDGELECT PLUMB MECH
OO PERMIT ISSUANCE, l �LjJ El 11
LICENSED CONTRACTOR'S DECLARATION pPPL1ANCLS-RESIDENTW, LOB DESCRIPTION
herebyi ffirm hat I rum I tensed underprovisionsof Chapter9(commencingwith
Section]000)of Division 3 of the Business and Professions Cade,and my license is in PANELS
yy�U full farce and effect.
FaZu1 License Class Lit.# UP TO 200 AMPS
to< Data Contractor
Fo, 201-10 AMS
Z
ARCHITECTS DECLARATION SQ.Ff.FLOOR AREA $/SQ.FT.
Z0,,-Z N^ I understand my plans shall be used as public records. OVER 10011 AMPS
y SIGNS ELECTRICAL
Licensed Professional
�ky.CQ
OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
iya�(DaF 1 hereby affirm that I ata exempt from the Contractor's License law for the
tR3LLm following reamn.(Sedion]03L5,Business unit Professions Code:Any cityiummay TEMP.METER OR POLE INST.
1>->!w, which requires u permitlm construct,she,,improve,demolish,orrepair anysuucmrc prior to its issuance,also retains Ne mrlicamfor such permit to rile a signed statement POWER DEVICES
p that he is licensed pursuantto the Provisions mfthe Comtrtcmrs License Law(Chapter9(commencing with Section]1100)ofDivision 3 ofhe Business wl Professions Code) SWIMMING POOL ELECTRIC VALUAATION
„m or that he is exempttherefrom and the basis for the alleged exemption.Any violmiomof OUTLETS-SWITCI{lig-FIXTURES �O O�
�ZQSection 7031.5 by any applicoat for a permit subjects the applicant to a civil penalty of
K�mnot more than fiver hundred dollars($500). NEW RESIDENTIAL.ELECIR _SQ
❑ I,uownemRhepropcny,mmyemployttswith wagnesheirsolecompematiom x STORIES TYPECONSTRUCTION
will do the work,add theatbalmebettor intended oroffered far sue(Sm 7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner ofpomi
ownemploy s.pmyi{m aveshimp vnd whoements doessuchode moffef forthrough his L �O[C�GROUP w .UNI S
howemplayethe buddinidedharoveh impmvemwithin err astr fcmoffertd forowner- MCP R
bowevegillhav l the
buries of
is he iinoaoyear or improefort purpose
f T
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,u owncrafthepropeny.amexdusivdy contracting with licensed cantrsctonw QTY. PLUMBING PERMIT FEE DTE F1'OOD 20N / APN
construct the project(Sec.7094.Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law does not apply Ion ownerofpropery who builds or improves hereon,and
who contracts forsuch Projects with acon rucmr(a)licensed pursuant lathe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B At P C far this town BACK FLOW PROTECT.DEVICE OUTSIDE FEB
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND. SCHOOLTAX Y_N
❑ Ihcrebyaffirm that l have a cerifiale ofmment to ulf-insum,or a mrifeateaf FIXTURES-PER TRAP RECEIPTp
Workers Compensation lasumn<emacerifirdcapytherrof(See.3S00-Iab C.)which PARK FEE YN
covers all employee's under this permit. GAS-EA, TEM
SYS -I INCA OUTLETS RECEIPT N
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby burnished.
❑ Certified copy is filed with the city inspection division. GREASEgNDUSTRL WASTE INTERCEPTOR GRADINGFEE
CERTIFICATE OF EXGMPf10N FROM WORKERS' GREASETRAP SOILS FEB
COMPENSATION INSURANCE
(This section need not be completed ifhe permit is forom hundroddollars($IN) SEWER-SANITARY-STORM EA.2WIT. ENERGY FEE
of leas.)
I certify but in the performance of ilia work for which this permit is issued.)shall WATI7R HGTER WNTNT/ELECfR
not employ any person in any manner so as to become subject to he Workers PAID
Compensation Lawsof Celifamia. Data WATER SYSTEMITREATING Date Receipt#
,2 Applicant
z 0 NOTICE TO APPLICANT:ILafmr making this Certificate of Exemption,youshnuld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r-I LoO become subject to he Workers Compensation provisions of the Labor Cade,you must 0
Oforthwith comply with such Provisions or this permit shall be dium al revoked. BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 I hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC E
U O the work for which this permit is issued(Ste.3(9],Civ.C.) �
landres Name
Ll. F Leaders Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
V I certify that I have mad this application and suite that the above information is
correct.I agree to comply with all city sumcounty ordinances and slow laws reining to PERMIT ISSUANCE. MECHANICAL FEE
f-' building construction,and hereby auhntiu repssenuitives ofthis city toaster upon the CONSTRUCTIONTAX
V Z move-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree on save,indemnify and keep hmmlesa the City of Cupertino agurrt
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,0(10 CFM)
in co; a of tie y�nming of this it.
S a (J/ /10 moi• AIR HANDLING UNIT(OVER 10,000 CFM)
ignature of Applicant/Contmctor Dam_ (� EiMAUSTHOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building occupant stare or handle hazardous materia HEATING UNIT(OVER 100,000 BTU)
m defined by the Caperton Municipal Cade,Chapter 9.12,end the Health and Safety
Crufc,Section 25932(n)Y
11 yes ❑No VENTILATION FAN(SINGLE RESID)
Will thea licardiefumrebuildin «cu BOILER-COMP(3HP OR IN,"BTU) ISSUANCEDATE
pp g pentose equipmcnmrdevireswhich emit
hazardous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER❑ 100,00 BTU) p
District? A G
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. s#I /
I have read he hazardous materials requirements under Chapter 6.95 of the ��
California Health&lSafety Code,Sections 25505,25533 and 25534. I understood hart {/
if he building does not currently have a tenant,that it is my responsibility to notify the a.
Ocmant of he rec iremems which most beat prior to is..of a Ccrifate of I (//
ccupancy.
y
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE