25213 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD IN"—hLECC
TRTCA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROD CT IDENTICAL 2 5 2 1 3
IIUILDING PROJECT'HIEN"TIVICATION
BUILDING ADDRESS: ,(/ / //,' ,f SANITARY NO. APPLICATIONSUBMITTALDAD
c e / �L 6L 'eirfim LOT# G �«
OWNS AME: PHONE: O RACfOR'S NAM+: LIC NO:
1, N/C CONTROL#
ARCH]IhU/ENGINEER: LIC NO: ADDRESS: _ l�s c7 C O �e
s I �erz
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUIL TNG PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El 1:3
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB
ne&Z I hereby affirm that l am licensed underprovisions of Chapmr9(commencing with DESCRIPTION
F100 Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
Fapp��44-.. fullforce nseclnd e[fxr7q 37y ZZ( UP TO 2W AMPS
W z yUj License Cluns_ScL.._L Lic.p
h=y Dam Connector 201-1000 AMPS
Z�NZ ARCHITECTS DECLARATION OVER IO00AMPS SQ.FT.FLOOR ARE $/SQ.FT.
O'L I understand my plans shall be used m public retards.
1=rnFul SIGNS ELECTRICAL rs ® �T
QS6dd ; Licensed Professional C'\1
�ya'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOaF 1 hereby affirm that I am exempt from the Contracmts License law for the fk /I 1--� ;I ;I
W 3 rn following rcamn.(Seainn]03 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. III•IJJ6.111 �L/ II1.JI' {•`s
which requires a permit to construct,alter,improve,demolish,or repair any structure
znn:: prior to its issuance,atm requires theapplicant fm such permit to file me,ned.mens POWER DEVICES
tyK<0 that he is licensed pursuant to flue provisions of the Comracmrs License Law(Chapter
a,,.X 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC
y or that be is exempt Ncrcfmm and the basis for the alleged exemption.Any violation of
Z G m
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
n t ore than live hundred deal lars($5W).
= . ❑ I,nowncrafNcprnpmy,ormycmployces withwegcsn Neirsole<ompcnsetion, NEWRESIDENTIAL ELECfR _SQ.FT. STORIES TYPECONSTRUCTIGC
63222 will do the work,and thesracturcis not imended oreffered forsole(SecJf4W,Business
and Professions Code:'1'he Conmocmr's License Law does not apply to an owner of
profanity who builds orimproves t umesmand whodoes such work himselforthmughhis
own employees provided Nmauch imp mvcriteria are no,mandedor offered forsale.If, OCC.GROUP RFS.UNITS
however,Ne buildingor imprevemcm is sold within one yearo(completion,theovenn- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.),
❑ I,mownerof Ncpupcny.amexelusivelyconimetingwiNliccn dcmm tomto QTY' PLUMBING PERMIT FEE FLOODZONE APN
common the pojat(Sec.TBe4,Business and professions Code:)The Contractor's
License Law Jnesnurnpply to an ownuofnmeny wbobuildsorimproves thereon,and PERMIT ISSUANCE
who contract focsuch projects with a cormorants)licensed Financed India Contractor's ALTER (EA)
License Law. FEE SUMMARY
❑ I um exanpt under Sec. ,B&P C fur this mason BACK FLOW PROTECT.DEVICE OUTSIDE ZEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
t N
fmm
❑ 1hereby afthat l have accnificam electrical mself-insure,oracenlficamof FlXTURES-PER TRAP RF.CEIPI'#
Workers'Compensation Insurance r a certified copy themof(Sec.SIM,Lab C.)which PARK FEE Y N__
Policy N /
en all employesss+mtl#r/giyfagrrpys5 � GAS-EA.SYSTEMOUTLETS
-I INC.4 RECEIPTis
/ T7�Y'J /
Company Cf b tt / BUILDING DIVISION FEES
❑ CentlicJ a+pytYercby fumrshM " - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ME
❑ Certified copy is Bled with the city inspection division. OREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section rad notbc completed ifthe permit is become hundred dollars(SIM) SEWER-SANITARY-STORM EA.200111 ENERGY FEE
ear less.)
I certify that in the performance ofthe work for which this Permit is issued,I shell WATER HEATER W/VENT/ELECI'R
not empby any Person in any manner so as to become subject to the Workers' PAID
Compensation Laws mf California. Date WATER SYSTEM/BEATING Data Receipt#
Q Z Applicant -
yNOTICE TOAPPLICANT:If.after making this Cenificate of ExempJom,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:beconm subject a the Worker's Compensation Persian.ofthe labor Cade,you must
a > forthwith comply with such pavisium or this permit shall be demand revoked. BUILDINGFEE
y D CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that there is a connection lending agency for the performance of
U C) the work for which this Permit is issued(Sec.301 Civ,C.) TOTAL: ELECTRIC FEE
P. ,odds Name
O U larder's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and state that the above information is
F6. carters. l agree m comply with all city and county ordinances and sone laws rclatingm PERMIT ISSUANCE MECHANICAL FEE
building convection,and hereby euthov<rcpmentafivm of Nis city memnmpon the
U Z above-mentioned property for inspection purposes. ACI'ER OR ADD TO MECFI. CONSTRUCTION TAX
We)agree to save,indemnify and luip harmless Ne City of Cupertino against
liabilitiesjudgments.costssndexperson. icynay is any wayacemea,oust said City AIR HANDLING ON IT(TO I0J000 CFM)
in e cnf Nc r ting of this pe
(7. p AIR HANDLING UNIT(OVER IO,000 CFM)
Signature ofzi
A tical/Conamelr Date EXHAUSTHOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT I TO Be,"BTU) Dam Receipt#
Will the xppliem,or future building occupant stare or handle hazardous material
as defined by the Calcium Municipal Cale,Chapter 9.12.and Ne HeaIN and Safety HEATING UNIT(OVER 10QO00 BTU) TOTAL:
Code,Sion 25532m)]
11 yea 12 No VENTILATION FAN(SINGLE RESID)
Will Neapplicanmrfuturebulldingoecu ant use BOILER-COMP(311'OR 100,000 BTU) ISSUANCE DATE
p cquipmat odevitts whicM1 emit
hmemons air comaminums as defined by Ne Be,Area Air Quality Management pp
District] BOILER-COMP(OVF.R 10100j", BTU) 11� 8
1)Yea CI No NEW RESIDENTIAL MECII. SQ.FT. pp��jj 141
I have mad the hxwdaus materials requirements under Chapter 6.95 of the // I ts�,s.
Cnlifomiu Health&Safely Code,Scene.,2.5505.25533 and 25534. 1 undecaund Not i r J ■RYI 17 ���q
racit upeint of gdocvnmements which
m mnnm.Nmiilr myssuanc responsibility Ne 3
occupant nb Nc es not currently
ere which must a met poor m issuance of it Cto unit a of
Occupancy. Cl I Y UP ' tr.,1:.L
Owner or nme
uthocJ agent Da
TOTAL ISSIIBU BY: