25310 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES..USE BALL POINT PEN ONLY 11
CITY OF CUPERTINO - C■ BUILDING.ELECTIAL •� PERMIT No.
APPLICATION/PER IT PLUMBING-MECHANICAL. 5 1] O
BUILDING DIVISION BUILBINGPROJECT� OFICATION J J
BUILDING ADDRESS: o - ^ SANITARY NO. APPLICATIONSURMrITALDATE
0531 Gas i AOI UNIT# LOT# �7sQ
OW //NAME:
PRONE (RWS NAME: LIC NO:
NEC151� 1671
CONTROL
ARCHITECTFNGINEER: RS o ❑
_ Vl �� � #
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH '
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
Amz' I hereby affirm that l sm licensed under provisions of Chapter 9(commencing with
L400 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS /��/�o rte++
Fa�E full force and effyst.�. Lo,11-3 'q 1�� UPT0200AMN ee_ 1 ` •�\
W License lass r�y�b
as
a Dure Convector 201-1000 AMPS
F'�rn ARCHITECTS DEC ARANO SQ.PT.FLOOR AREA $/SQ.IT.
OZ,°',A I understand my plans shall be used as public records. OVER 1000 AMPS
SIGNS ELECTRICAL f
44��dd LlcensW Professional
Eu OWNER-BUILDER DECLARATION SPECIAL CIRNIT/MISC. E ® I N
O 1 hereby affirm that I am exempt from the Contracmr'e License Use for the
as following rcaeon.(Semon 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F❑ a which requires a permit to consw<l,alter,improve,demolish,or repair any structure
ER
7 mannilto file mantra its issuance,also requires the applicant for such penle a signed statement POWER DEVICES r
W W ursoem to the provisions of the Contractor's License Lew(Chapter
00 that he is licensed p -
d0.o 9(commencing with Section7fifil of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC D 0 rE VALU ION
iWMw or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURE
zQ Section 9031.5 by any applicant fur a permit subjects the epplicanno a civil pe rally of
�onot more than five hundred dollars($500). NEW RESIDCNTIAL EL[CTR _SQ.PI'.
❑ l,asownerofthe r,orm m to eeswithwa esastheirsolecom ensadon. STORIES TYPE CONSTRUCTION
o PmPery Ye P Y B P
i3= will do he work,andN struclumThe Conammo's Lie a se Law ard does not
apply Ta 44,Business
and Professions Code:The Co thereon,
a License Lew does or apply lf an owner of I
is
property whobuilds orimprnvee thereon,and whodcessoch workhimselforNrough Me OCC.GROUP RES.UNITS
employees,lding ori Nntauchimpmvementein one
eyear exampleercd them nIf,
howeer,will have
urimproprovinement g that ed id not build or improve
omm efor the f TOTAL:
builder will have the burden of proving that he did not build m improve for purpose of
am.).
❑ I,esownerof the property,em exclueivelycontrecting with licrnsed conrtacmmto Qom' PLUMBING PERMIT F68 FLOOD ZONE APN
answer the project(Sec.7144,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
71G,_00til-
License Law does not apply toanownsrefpropertywho builds mimproves therson,and
whoconvacts forsuch projects with aconlraclons,licensed pursuant to the Contractors
License Law. ALTER-DRAINffi VENT-WATER(EA) FEE SUMMARY
❑ I ora exempt under Sec. ,B&P C for chis reason BACK FLOW PROTECT.DEVICE. OU`JSIDEFMS
SANITARY Y N
Owner Date DRAINS-FLOORROOF, RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX V N
❑ Thereby affiant NaU havencertificntc of eonunuos<IGinsure,nraeertifcate of FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance aro rarified c.,floreof(Sec.3800,Lab C.)which PARKFBE Y N
covers all employees' under this permit, GAS-E .SYSTEM-1 INC.40UTLETS
RECEIPT#
Policy#
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby humanist
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This mcion need not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM F.A.MET. ENERGY FEE
or less.)
I eerily Nalm ma performance mine work for which this permit is issued,Is hall WATER HEATER W/VENT/ELECTR
not employ any person in my manner so as 0 become subject to the Workeri PAID
Compensation Lawsof Califomla. Dale WATER SYSTEMGMEATING Date Receipt It
Z Applicant
0 0. NOTICE TO APPLICANT:If,after making this Certificate of Exemption, TOTAL:
,Z ti g p inn,you should NEW RESIDENTIAL PLMB. SQ.PI'.
V) hecome subject the Worker's Compensation provisions of the Labor Code,you must
wit -
fotthh comply
wiN such
provisions or permit shell be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of
Uthe work for which this permit is issued(Sec.3097,Civ.C.) TO ELECTRIC FEE
pP Lenders Name I �a
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U
U I certify that I have read this application and .is that the above information is MECHANICAL FEE
H0. coned.Iagreemcomptywlthalleityandcountymdinencesandinowlawsrelalingto PERMITISSUANCE
building construction,and hereby amhorim representatives of this city in enter upon Ne CONSTRUCTION TAX
U 'Z above-mentioned property for inspection purposes. ALTER OR ADO TO MECH.
(We)agree to save.Indemnify Dad keep harmless the City of Cupertino against
liabililies,judgments,c is mdoxpenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00)CFM)
asequence of ming of Nis pe it.
AIR HANDLING UNIT(OVER 10,000 CPM)
7"
Signatureo pp¢an ontracto Date EXHAUST HOOD(W/DUCIG
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL
as defined by the Cupcnlao Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sorm.25532(a)? VENTILATION FAN(SINGLE RESID)
E)Yes C3No
Will the a cormorants as define by the
Ana
Air Quality es Management /nn
BOILER-COME(3HPOR 100,00(BTU) IS UA
huimdous air contaminants as defined by the Bay Aree Air Quality Management BOILER-COMP(OVER 100,00d)BTU) 34 131993 .
District! 1111H. 1993
Yee No NEW RESIDENTIAL MECSQ.FT.
1 have read the Safety
Come materials on,5505,25533 under Chapter understand
0(the Wrt�/�Ivv
if the
uil Health s Safely Code,Sermons 25505,25533 and responsibility
I understand Net
ifthebuildingacesnot
mentscurrently have asnan4 thinitis myomanceoila enotify Ne
Occupant of the requirements which must Be met prior to iseuence of a Certificate of
Occupancy.
Owner or aurhoriud again pate TOTAL: ISSUED BY:
OFFICE
1 ADDITIONAL PERMIT FEES ,
-BUILDING PROJECT I DENT[FICATION- - VA LOATION -
BUILpING -
PpOPESS
FEE SUMMARY
H'MEFAcroFs - -' - BUILDING
uc NO PLAN CHECK
coxrFAcrons FEE -
CONFESS
PNoxE - - - SEISMIC FEE
QTY. ELECTRIC PERMIT 'FEE '
r-
OUTLETS:SWITCHES-RECEP 6A S - . ELECTRIC. r^' -
LL f} LIGHTING FIXTURES f'��]Lir PLUMBING
- PPLIANCES-RESIDENTIAL ' -
PANELS - _ MECHANICAL -
SIGNS- -
_ SIGNSTRANS. - - TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS - ' SEE FEE SCH. -
O; 1 SERVICE CHANGE-
a _ TOTAL Hri 9 A•
DATE
LU
a, DTV. PLUMBING PERMIT f�E` (e�EToc�., etErp, PLG. MECN.
.� Z ALTER-DRAIN&VENT-WATER(EA.): - - 1=I n ❑ ❑
U'2 BACK F,LOW PROTECT.DEVICE "
H.
OO DRAINS-FLOOR,ROOF,ARE&GOND. - -_
d FIXTURES-PERTRAP
Z. GAS-EA.SYSTEM-1 INC.40UTLETS
.. .0 GAS-EA.SYSTEM-OVER 4(EA.) - -
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWNSPRINKLERS-O51EA.1
-
SEWER-SANITARY-STORM EA.200h/ i^� .-
WATER HEATER W/VENT. [�
WATER SYSTEM _
WATER TREATING EQUIP. IOTAL
-
p
? 4-
OTV. MECHANICAL PERMIT FEE pp��
ALTER OR ADD TO MECH. p�
- A 9
APPLIANCE -
AIR HANDLING UNIT(TOIOMC.E.M) ,���yE, - -_
AIR HANDLING UNIT(OVER I0=C.F.M,) /d 1,Y y�
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.) I CS+UCCrI LIflu
. . HEATING UNIT(OVER 100,000 B.T.U.1 ' -
VENTILATIONFAN,(SINGLE) -
BOILER-CONY(3 H.P.0,10D,DOO B.T.U.)
BOILER-COMP 10-1100,000 BTU)SEE EEE SCR.
TOTAL