25110APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' CITY OF CUPERTINO B ILLDING-ELECT HICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL �%C'i 'i O
IIIIII.IIINI. PNII IV, IIIFNTINI".'VIN L J 11
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ARCtIITELT/ENGIN[F.R:
ADDRESS:
❑
OCC. GROUP
CONTACT: PHONE:
QTY, ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
PERMIT ISSUANCE
builder will have the burden of proving that he did not build or improve for purpose of
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LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that ten licensed underprovisionsofChapler9om
(cmencingwith
Section 70fa11)of Divison 3 of [be Business and Professions CWe, and my license is in
full force and effect. r
APPLIANCES - RESIDENTIAL
PANELS
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License ClassLic.p
Date Contmetor
UP TO 200 AMPS
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201 - HOW AMPS
ARCHITECPSDECLARATfON
IunAcmmmA my plans shall be used ua public recoNa.
OVER TWO AMPS
SQ. PT. FLOOR AREA
L E D I N
E/SQ.1
SIGNS ELECTRICAL
Licensed Professional
jpy G
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
SANITARY Y N
RECEIPT,i
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1 hereby affirm she, 1 am exempt from the Cmaructit , License Law both
fallowing reason.(Section 7031.5. Businessond Professions Code: Any city orcounty
which requites a permit to construct, alter, improve, demolish, or repair any tantrum
prior to its is.umnce, also requires the applicant for such Permit rile a signed common
that he is licensed mons oam m the previsions of the Conmecur'a License Law (Chepmr
9(commebcing with Section laid) of Division 3 ofthe Business and Professions Code)
TEMP. METER OR POLE INST.
P C R
G
SCHOOLTAX Y N
POWER DEVICES
SWIMMING POOL ELECTRIC
U
AILO
❑y
tFz
.,,hot he isexempnherefromund the basis fonheallegedexemnion. Any violitionof
Section7031.5 by any applicant for. perosit subjecusheapplicanuoa civil penally of
n ithanfive hundredJolles 5o07.
fit 1 ..e�x....o. m.1.1.......,.
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
OUTLETS-SWITCIILS-Pq(Tl1RES
NEW RESIDENTIAL ELFCIR _SQ. FT.
gTOR11STVPECDNti'IR11[
red Professions Code: The Contractors License Law docs not apply to an owner of
ropersy who builds or improves thereon, and whodoes such workhimselforthrough his
own employees, provided that such improvemenuare not intended or offered forssle. If,
OCC. GROUP
RES. NITS
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however, the buildingor improvement is sold within oneyearofcomphow, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
xi
❑ I, as ownmof the property, um exclusively contracting with licensed commemmto
FLOOD -LONE
APN
construct the project (Sec. 70a4, Business and Professions Codc)'Ile Contractor's
License Law does not apply to an ownerefpropeny who builds or improves thereon,ond
PERMIT ISSUANCE
who contractsforsuch projects with a contrast licensed pumuant to the Contractors
License Law.
ALTER VENT WATER (EA)
FEE SUMMARY
❑ I Ins exempt uMer Scc. tl & P C for this reason
BACK FLOW PROTECT. DEVICE
E
SANITARY Y N
RECEIPT,i
Owner Dare
DRAINS-PLIX)0., ROOF, AREA, COND.
-
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Thereby affimtthm thous acenificom of ronscnuo ulGinxurc, nrecenificam of
Worken'Cnmpensmion lnsurwceorattnificd copy thereof(Sec.3g00, Lab C.) which
RBCEIPTp
FIXTURES -PP.R TRAP
PARK FET? YN
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
covers all employee's under this permit.
Policy N
RECEIPT N
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 EA)
PLANCHECK FEE
❑ Cenifed copy is hereby famished.
GREASWINDUSTRL WASTE INTERCEPTOR
GRADING RE
❑ Ccnified copy is fled with the city ivpeaian division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASF.TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not he completed ifthe permit is for one hundred dollars f$ 100)
nrleass.)
WATER HEATER W/VENT/ELECIt
I certify that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any manner ao as to become subject to the Workers
PAID
Z
Compensation laws of Calil'nmie. Data
Applicant
WATER SYSTFiM/IRFATING
Dam RccciptN
O 0
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL ELME. SQ. FT,
TOTAL:
r DO
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become subject o the Workers Compensation provisions of the labor Code, you must
fonocith comply with such provisions or permit shall be deemed .,cited.
BUILDING FEE
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IJ Othe
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CONSTRUCTION LENDING AGENCY
I hereby offirm that thus is a construction lending agency for Ne performance of
work for which this permit is issued (See 3097, Civ. C.)
Lenders Name
SEISMIC FEE
TOTAL:
ELECTRIC FEB
fender. Address
QTY. MECHANICAL PERM19' FEF:
PLUMBING FEF.
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I certify that 1 have read this opplication and sure that theabove information is
corers. lugmemcomply with all city and county ordinances andsmte laws relatingto
building construction, and hemby authorise representatives ofthis city m enter upon the
above-mommored property for inspection purposes.
PERMIT ISSUANCE
MECI IANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep Lurmless the City of Cupertino against
lishilities,judgmeme, costs and expenses which mayinanywayaccona agoinn tai City
AIR HANDLING UNIT ITC, I0O00 CPM)
inconvaVenceof the 0ngofthispermic eC
AIRHANDLINGUNIT(OVF.R IO,oIXICIM)
e ata n( lice oal r ate
EXHAUSTHOOD(WNUCq
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
Will the applicant car form building occupant some or handle huurdous material
as defined by the Cupenino Municipal Code, Chapter 9.12, and the Health end Safety
IIEiATING UNIT HOVER 100,00s) BTU)
TOTAL:
VENTILATION PAN SINGLESINGLERLSID)
Code, Section 2553200?
❑ Yes ❑ No
Willsheopomormtaainta.humid nBay cManagement
BOILER - COMP OHP OR 100,0X0 BTU)
ISSUANCE DATE
PAID
BOILER - COMP (OVER 100,000 BTU)
•Diatrinl
by theAre. Air Quality
Diwim us air contmminants as defined by the Bay Areu Air Quality Management
Dy.❑ No
Nt9
SAY 2g
NEW RESIDETI
NAh MECH. SQ. PI'.
1 have read the Institutions materials requirements under Chapter 6.95 of the
California I earth & Safety Code , Sections 25505, 25533 and 25534. 1 undoo and that
1993
/l
if the building does out commit, have. tenant, that it is my responsibility to notify the
occupant of the requirements which must he mu prior to issuance of u Ceni sumo of
Vr Wry
Occupancy.
ISSUED BY:
Owner or authorised agent Data
TOTAL: