25921APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMITKILECIRICAL
BUILDING DIVISION PING PROD - T IDENTIFICATION
BUILDING PROJECT IDENTIFICATION
PERMIT No.
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
UNIT# LOT#
ik:
1
W ig5 E PHONE:
CONTRACTOR'S NAME: LIC NOso
N/C
❑
CONTROL#
E uo.� W s ear. GZo
IARCHIFEUMNUINItEW LIC NO:
USS:
o tnalco 2,p m. c�Ace-r��m,
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El El
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thatl om licensed underprovistonsof Chapterr) mommenciagwith
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Semon it of Division 3 of the Business and Professions Code, and my license is in
Pon fmco .md,ffec
las-. _^ 6• Uc.# 4 .12.
PANELS
UPT0200AMPS
�,—
Dara Contra= mVO N4st �({w+�
201 - 1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall he used as public records.
OVER 1000 AMPS
r$Q Qf11�AREpI IN R
p8� 16.11, Ilii u\Vp
$/SQ. FT.
SIGNS ELECTRICAL
�G�nk Y
Y V Y U Y E Y^r�
it Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC. 1 ,o v
I hereby affirm Nat I am exempt from the Cmd adors License Law for the
following reason (Section ]031.5, Business end Profeseiom Cade: Any city or county
TEMP. METER OR POLE INST.�
which requires a permit m construct, eller. improve, demolish, or repair any structure
priocm its kamam.1mrequires thenpplimm for inclination no file. signedaretensin
POWER DEVICES
that he is licensed pursuant to the provisions of the Commuctor's License Law (Chapter
9(commencing with Section 7000) of Division 3 of the Businessind Profee&ions Code)
or that he is exempt therefrom and the basis fm the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
not more than five hundred doll., ($500).
❑ I,asownerofthepropny,ormyemployeeswithwagesazNeirsolewmpeasaden,
NEWRESIDENTIALELECTR_SQ.FT.
STORIES
TYPE CONSTRUCTION
will dothe work, and the shuctureis not intemdedoroffered for sale(Sec. 7044, Business
'
and Professions Code: The Contmclors License Low does not apply to an owner of
poi who b uil ds cr i mproves (bereon, and who does such work himsel f or thmugh hie
wnemployees,providedthatsuchimprovemente arcnotimm�dedorofferedforsale. If,
OCC. GROUP
RES. UNITS
however, the buildingor improvement is sold within oneye.of completion, the owner-
builder will have the burden ofpmving thin he did not build or improve for purpose of
TOTAL:
QTY. PLUMBING PERMIT FEE
sale.).
❑ I,uownerofthepropeny,amexclusivelycommctingwiNliccnsedconvctonto
FLOODZONE
APN
construct the project (Seo. 7044, Business and Pommosioas Cmde) The Contractor's
License Law dualmn apply tb an ownerofpmpcoy who builds or improves thmeon,mitPERMIT
ISSUANCE
who contracts forxch projects with. contractors) licensed pursuentm rhe Coauucmr&
License Low.
ALTER (E )
FEE SUMMARY
❑ l am exempt under Sec. , B & P C for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEE
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Ihereby affirm that I have a ttnificam ofecosent to self -insure, or a certificateof
Workers'Compensationlnsurencemace ifiedcopythereo((Seco 3800, Lab CJ which
SCHOOLTAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
covers all employee's under this permit
Policy #
GAS - EA. SYSTEM- INC. OUTLETS
RECEIPTN
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
_ enified copy is hereby famished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING HE
nified copy is filed with the city inspeetion division.
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
SEWER -SANITARY -STORM EA. 20)
ENERGY FEE
(This section need no ted completed firm, permit is for one hundred dollim S 100)
or less.)
W W/VENT/ELECTR
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers'
PAID
Compensation Lows of Calif an ia. Date
Applicant
WATER SYST /TREATING
Dete Receipt #
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation Provisions of the Labor Cede, you must
SIDENTIAL PLMIL SQ. FT.
TOTAL:
forthwith comply with such provisions or this permit shall Be deemed revoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for the performance of
TOTAL:
ELECTRIC FEE
the work for which this permit is issued (See. 3197, Civ. C.)
Lender's Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify, that I have read this application and state that to above information is
comet I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingconmclion, nndhereby autionu representatives ofthis city minter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupmdno against
liabilities,judgments, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT (OVER IQ000 CFM)
mgnamre of Applicant/Concomor Date
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO 100.00( BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dale Receipt#
Will the applicant or future building overprnt&into or handle hazardous material
as defined by the C rtim Municipal Code, Chapter9.12, it the Health and Safety
HEATING UNIT (OVER 100,0110 BTU)
Code, Stedon 25532(.)3
❑ Yes ❑ No
VENTILATION FAN (SINGLE RHSID)
-
Will thee licanmrfulure buildin
pp g by due Bay equipment Qualities&whichemit
hiamcrus air contaminants as defined by the Bay Aren Air Quality Management
DlsmcR
BOILER - COMP (3HP OR IW,000 BTU) ,
ISSUANCE DATE
'
BOILER - COMP(OVER 100,W) BTU)
❑Yes 11 No
I have read the haz.dous materials requirements under Chapter 6.95 of the
FEB 15 1994
NEW RESIDENTIAL MECH. SQ. PT.
(understand that
Health& Safely Code, avea to 25505,25533 and responsibility
if the building
i ccupanilof the requiremnot ents
cwpem of the requiremems which must be met prior to issuance m(a Cenificele of
nts currently h must bm. that it my reuance of ty to notifytheof
C�iY u
V 1 Vr �I(�il.l'(I Try
Occupancy.
•f'
ISSUED BY
Ownpancy. horiud agent Date
TOTAL:
(L)"1uh