25504 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUIL UING-ELEC RICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 5[v O A
BUILDING DIVISION 4
BUILDING PROJEC"I'IDENTIFICATION J J
BUILDING ADDRESS:�(`, e ' SANITARY NO. APPLICATION SUBMITTAL DATE
e m i/ R." LOTis
NI ME: PHONE: A R'S E: /' IC NO: PIC CONROLN
nRCfI ITECT/ENGINEF.R: LIC NO: —4
S§O SGAI
J e
IQ NOW
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMII'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Cimz Iherebyaf@m that lam licenaeJanderprovkinmm'Cluvpmrt)bumuncromgwim JOB DESCRIPTION
X00 S0C11orcPANELS
eon (aod eLc)(if Division 3 ofthe wMca��a and w.wions Coe. nylicense is in UP TO AMPS
95 Gl-h�N11.�c
s Qy to Compost., 201-IUW AMPS vow
`J.OyZ R III rECTS DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.Ff.
O7_O 1 understand my plans shall be used as public records.
F,ro E-; SIGNS ELECTRICAL
Z Y Licensed Prufe"mu d
%w< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
al 1 hereby affirm that 13I .Basin from the Cocoons Co License Law for the
m 3 a ce isfollowing ims is (Section 703 L5.t,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit re construct,alter,improve,demolish,or repair any stricture
E YE thionei lickowme,ensed
dp ts.requires theapplicantof the Ci pemtiun file a Lie...signed statement POWER DEVICES
u�J a00 9(ecothat islicemeJpurection 0 of Division the C,Business
license Law(Chapter
Y(commcncing with SeetionlWO)nf Division3of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUAT
^y or that he is exempt therefrom and the basis for the alleged exemption.Any violationaf
F$$-Z$ Semion7031.5byanyapplicamt upemhymf OUTLETS-SWITCHES-FIXTURESQ not are than fehnJddolla ($500).
m ��••�I�
NF,WRESIDENTIALELECTR _SQ.M.
W
W ❑ I,asowncrnfh,eprnperty,ormyemployeeswitbwagesasiheirsolecompcnsation, STORIES TYPECONS"IRUCTION
3— will do the work.cad the squnture isnot intended orofrercafor sale(Set.7044,Business
and Professions Code:The Commerce,License Law does not apply to an owner of
property who m i ld s or i mpfnvea Chemo m and wh s does such work m Ouse if orrhrough his
own employees,provided that such improvcmeutsare not imendedurefFeted forsale.if, I GROUP RES.UNITS
however,the buildinger improvement is sold within one year of complction,meownen
builder will have the burden of that he did not build or ice for TOTAL:
proving prove purpose of yyy
sale.). QTY. PLUMBING PERMIT S70 D ONE ppry
❑ I,asowncrof the prnpeny,ace exclusively contmetivg with li«rvsed<ontmdors to r�
consumer the project(Sec.70K ,Business and Profeaslons Code:)Me Contractor's 1 n
icenu ro
Lawdoes not apply toanownefproperty whobuildaor improves thereon,and PERMIT ISSUANCE R
whoccummcts for such projects with a contrammus)licensed pursuant o the Contramors
License Law. ALTER (EAG, uv
ARY
❑ 1 am cxcntpt under Scc. ,B&P C for this reason BACK FLOW PROTECT.DEVICE DATE 'FEE
Owner Dam N
DRAINS-FLOOR.ROOF,AREA,GOND. ECE
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihemhyafnrm that l have acenincate reinvent m self-msure.ora certificamof FIXTURES-PIiR TRAP RECEIPTM
Workers'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT is
Polcy k BUILDING DIVISION FEES
wc any GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Sxunified copy is hereby furnish W.
❑ Wiled copy is Bled will city inspection Jivisiom GRFASRINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF 17XEMMON FROM WORKERS' GREASE TRAP
SOILS ME
COMPENSATION INSURANCE.
(This section need not be completed June pnrnii is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I certify that in the performance ufthe work for which this pconit is issued.i shall WATER HEATER W/VENT/ELECTR
nor employ any person in any manner so as;to become subject to the Workers' PAID
Compensation Lawsuf Caiifomia. Dam WATER SYSTEM/IRGTING
O z Applicant — Dam Receipt
z C) NOTICE TO APPLICANT:If,after making this Certificate of Exit........could NEW RESIDENTIAL PLM B. SQ.FT. TOTAL:
Cl� become subject to the Workers Compensation provisions of the labor Cale,you must
� > forthwith comply with such provisions or this permit shall IN,deemed revoked. BUILDINGFEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O theworkfor which thispcmJt is issued(Sca 3097,Civ.C.)
1<nder's Name
QF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have mad this application and state that the above information is
s1" a correct.l agree to comply with all city and county ordinances and state laws relatingm PF.RMI'T ISSUANCE. MECHANICAL FEE
huildingeonstruction,and hereby authority representatives ofthis city wenmrupon the O CONSTRUCTION TAX z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
1 0 agree to save,indemnify and keep harmless the Cc 17C Cupertino agaimt
liubililms,jo, enls,costsand expenses which may inanyway uI againstssaid iIL IR HANDLING UNIT(TO 10,00)CFM)
amaeyuc colt gmnr+ng of hi. Nl•*01AM
�^ AIR HANDLING UNIT(OVER 10,0100 CPM)
i
Si a re A cam/C5 p r Dam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0110 BTU) Date Receipt b
Will the applicant or future building complain sture or handle haaushms material HEATING UNIT(OVER 100.OW BTU) TOTAL]
as defined by the Cu actio Municipal Code.Chapter 9.12,and the Health and Safety
Cure,Section 25532(.)1
❑Yes El No VENTILATION PAN(SINGLF.RESID)
BOILER-COMP L3HP OR 100,000 BTU) ISSUANCE DATE
Will the apprearriaut orfumre deffired oy ffii, ay Am.Air ofality Mwhi,groom pp
hazardous vir comaminen¢as deMCJ by the Buy Area Air Quality Management BOILER-COMP(OVER 1(0,100 BTU) P A Q D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ,pT.
I have read the h lardous maerials requlremsms under Chapter 6.95 of the hWi RYI 19
Odifemla I Icuhh&S.faty Code,Sections 25505,25533 and 25534. I oadcrxmndithat
ifthebuildingdoesnotcuremlyhaveatenant,matitismy mmenceof. tcomify rhe
Occupancy.upam of the requiremems which mus be me prior to issuance of a Ccnificam of Cu Vf ksUr T71❑y
Occupancy.
Owner or authorized agate Dam TOTAL: ISSUED BY:
OFFICE