25643 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO •- MECIIA - PeRMIrNo.
APPLICATION/PERMIT PING PROGCI IDENNIFIC
CAL
BUILDING DIVISION IIIl11.DING PNOJBCI'IDENIFICATI(1N 25643
HUILDING ADURI! S: SANITARY NO. APPLICATIONSUBMITTAL DATE!
f"s #
YI UNIT# LOT# /v/�
OV ERS NAMh) PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL
p
s�,\ HITBCI'/Ii14OINE LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �mx' P E3 C1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nmz Ihcmbyaff,.that larnlicemW underprovisionaofChapmr9(commencing with
00 Section 7tXayof Division 3 ofahe Basinessand Professions Code,andeny license is In PANELS
y� full tome and effect. l
<Z ly License Class Lic.p UP TO 20b AMPS
rFii<y Date Convector 201-10I10AMPS
F.z ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA Q.FT.
Z O yr OZ.p—p 1 understand my plains shell k used as public records. OVER 1000 AMPS y /�
�ri. ssf SIGNS ELECTRICAL /.V L E D
Licensed Professional S`\
SPECI
rDMISC.
as
OWNER-BUILDER DECLARATION THMP.METER
OR
f\ /I T'1.......1
�p(,OyF I hereby affirm that 1 can exempt from the Contractor's License Law one the J Ih\(.II 10.✓
W�+o,,Ia whichfollowing
et,ii s..i(Section W3Lmet..ineseand r Professions Code:Any city urcounty TEMP.METER OR POLE INST.
f❑"'�ON J which requires a permit re vires the
alter,improve,demolish,erre a sig any swcmrc '
2=<O pirdo.haiucsused promical 1.
requires throvisi ns of the ch Copemtiuv filLice se Lim(ned (Chapter
POWER DEVICES L f.
W C<p that he is licensed pun coon the provisions of the Co Business
License law(CNpter G
2 con 9t hat heisexemwith
terefon7000)he Division 3ohheed mossand.An,iow Cede) SWIMMING POOL ELECTRIC VALUATION
y �y or that h7031.5 by ary,Gomand the basiafor theallcgedexemptiun.Myvi amity of OUTLETS-SWITCHES-FIXTURES
4 no,
Section7031.5by a hundred
($50tmit subjects the applicant macivil Mnalty of
O not more Nan Ev,fthepny,ormyem). NEW RESIDENTIALELECUt —SQ.FT.
m ❑ othe wrk,an mestractumis not
S'1'ORII:S TYPE.CONSTRUCTION
ywill do the work,C d e:The Contractor's
tor's License La doesed not apply to an owner
ss
of
and property
who
Cede:The Contrerso s Littnu 4w docs not apply lf an owner of
property who buildsor improves th impmand who does such work oreffe uthrough his
employees,provideJ tha[auch improvements arenosimmndedoroffered for We.If, OCC.GROUP NES.UNITS
however,the huildingor improvement is sold within one year ofcompletion,the owner- / Oy+
TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of L
sale.).
❑ Las owner oftheproperty,am exclusively convening with licensed convectors In QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.70LL Business and Professions CWe:)The Convector) PERMIT ISSUANCE
License Law does not apply m an ownerof property who bui ids or improer
ves Nmn,and
who contacts for such projects with a wmramor(s)licensed pursuant mile,Convectors
License Law. ALTER.DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em exempt under Sec. ,B&P C for this reason BACK HOW PROTECT.DEV TCB OUTSIDE FEE,
SANITARY YN
Owner Dnm RECLIPT#
• DRAINS-FLOOR,ROOF,AREA,COND.
WOR MAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihcmbyelfitm Rl❑heveeceni8cem ofcorcum mulLinsum,ueunificem of RECEIPTp
Workers'Compenution Insurance or a um
unified copy themof(Sec.J8 ,LabCJ which FIXTURES-PER TRAP PARK FEE Y N
covers all employees under this permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT#
Policy# BUILDING DIVISION IEES
Company GAS-EA.SYSTEM-OVER 4 HLA) PLANCHECK FEE
❑ CenifiW copy is hereby famished.
❑ Certifiedcopy ie filed wiN Ne ciq inspccoon division. GRP.ASPANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXINMON FROM WORKERS' GRFASH TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundmildollun(Slm) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Ies..)
I cenify that in the performance of the work for which this permit is issued,I&hall WATER I I EATER W/VEN'1'/ELECTR
not employ any person in any manner ao as ro became subject Ito the Workers' PAID
Compensation lawof Califiorm. Dew WATER SYSTEMTRBATING Dam Exeeipt#
Applicans
� � a
z NOTICE TO APPLICANT:If,arm,making this Certificate of Exemption,you Mould NEW RESIDENTIAL PLNUL SQ.FT. TOTAL:
y become subject to the Workers Compenution provision.of the Labor Code,you must
(5$ > bnthprevisions m
with comply with such pvisions or this permit shall be deeed revoked. BUILDING FEB
LTa Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm thea them i.a conewction lending agency for the perfornmce of v
V O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
Loodei a None O PLUMBING FEE F Lenders Add.. QTY. MECHANICAL PERMIT FEE
L.1 1 cenify that 1 have read this application and stare that the above information is
correct l agree to comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICAL ME
building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
V 7 ahove-mcrninnW pmpeny for inspection purposes. ALTER OR ADD TO MECH.
•7 (We)agree to save,indemnify and keep harmless the City of Cupertino against
Rabilihms,judgmcen,costs andexpenseswhich r in any way.s,.gaioat lead City AIR HANDLING UNIT(1010,000 CFM)
in consequence of the grounding of this permit.
AIR HANDLING ON"(OVER 10,000 CFM)
Signature of Appliemit/Contmktor Date EXHAUST HOOD(W/DUCT)
rAID/
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITITO KXLM1BTLE emReceipt if
Will the applicant or fume building occupant at=or handle hem ous material �-
udefinedbytheNpeninoMunicipalCWe,Chapter 9.12,end the l health and Safety HEATING UNIT(OVER 100JW BTU) TOTAL:
Code,Section
Yea ❑No NT255320V❑ VENTILATION FAN(SINGLE RFXID)
Will theupplicunmrfumrcbuilJingsscupum useeyuipn¢nmrdevices whiehemii
BOILER-COMP(3HP OR 100,0W BTI) ISSUANCE DATE
• hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER Im,01TO BTU) ///j,3
District? ❑ P A 9 D
Yes ❑No NIiW REIA
SIDENTL MPAIi. SQ.IT.
1 have mail the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that OCT 1� 1993
if the building docs not curtently have a tenant tam it is mpm
y res .ihility to nmify the
occupant ol'the requirement which at be met prior to issmmce f e C 'III of
Occu 3 # Ut C t V
Own r reuthv'W.gem am TOTAL: ISSUED
OFFICE