25589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINGKLECTRIC AI, PERMITNO, 25589 C
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 2 5 5 8 Q 9
BUI IA I NO PROJECT I DENTIF'ICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
60,1 UNIT M LOT If —l�
OWN PS NAME: PHONE: CONTRALTO 'SHAME: LIC NO: l•
A - �5--a - a/�5 N/C CONTROLp
ARCHITECT/ENGINEER: LIC NO: 1 ADDRESS: ❑
CONTACT: PHONE: v BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMITISSUANCIE Ii✓<
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ljf
QWz I fambyaffirm that l am licensed under provisionsmChapter9(commencing with
Ia100 Section e and)of Division 3 of the Business and Professions Code,vest my licrnse is in PANELS "1 �✓' —_
tFy- fullnse ClndeffecL of:UPTO 200 AMPS
FZ1y License ClassContr
y Qrn Dam Conuecmr 201-1000AMPS
Fy ARCHITECTS DECLARATION SQ.Ff.FLOOR AREA S/SQ.Ff.
OVER 1000 AMPS
Oz—p I understand my plans shall be used as public records. �rp�
En _1 SIGNS ELECTRICAL �T!
g��C< LicensedProfessiona) OWNER-BUILDER DECLARATION SPECIALCIRCUR/MISC.
[v 3 LL��UI hereby affirm that 1 am exempt from the inmu License law for the ` ,v `-ems!` ' �
following hewn.(Section 703 1.5,Business and Professions Cade:Any city or county TEMP,METER OR POLE INST. E167t`� which regairesapermisI.emmtmm,at.,.improve.demolish,or.,I,anysouclure '"' -
}� Prior to iit,namece,dsarequma Neepplieant for such famnamfleasi'cal smamem POWER DEVICES
W p @nm he is Iccmed pursaam to the provisions of the Contractors License law(Chapter
dpx,p� 9(commencing with Section]000)of Division Sof Ne Business and Forfeet...Code) SWIMMING POOL ELECTRIC VALUATION
W ern or that he is exempt Nemfrom and the basis far the alleged exemption.My violation a( OUTLETS-SWITCHES-FIXTURES
4 Section 7031.5 by any applicant for a Permit subjects the applicant too civil penalty of
O m than fve It dollars(8500). NEW RESIDENTIAL ELF.CfIt SQ.PT.
Po Lasownerofthen,.,ny,armyernploymswithwagesas Ncirsolecompemtion, Q 0 NI 3 I P CONSTRUCTION
a 3.. w Ido the work,endtheswnumisnot inanded oroffercA(orsale(Sa.]04a,Businms
Profevaions Ceme:'The Contractor's License Law does not apply to an owner of ' 1
Progeny whobuilds or improves thercoaaad whodoessuchwork himselforthmugh his v .G U tRES.UNITS
own employers,provided Nm such improvements me not immodest or offered for We.If,
however,the building or improvement is sold within one year ofcampletion,Ne owner- TOTAL: A4 {
builder will have the burden of proving that he did not builder improve for purpose of L DATE
Ie.).
[31.asownerofthepmWny,amexclusivelycan=ting Mi iicensedc Comm QTY, PLUMBING PERMIT FEE Fl.000zonE
mamma the project(Sec.700,Business and Pmfcasi.Coded The Comtecmrs
License Law does not apply he anownerofproperty who buildsorimprovee thereon.and PERMIT ISSUANCE
whocommcesfor such projects with accomamur(s)licensed pursuantsothe Convectors ALTER (FA)
License law. FEE SUMMARY
❑ 1 am exempt under Sce. ,B&P C for this mason BACK FLOW PROTECT.DEVICE O T IDE
SANITARY YN
Owntt Dale RECEIPT 0
• ca DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ lhembyaffumthmlhave
are Or afeateofconunuose(Sesurgor Lab C.))care of RHCEII'I'M
Workers'Com FIXTURES-PEN TRAP
pemtionle,This eoracenifed copy Hereof(Sa.3g00,Lab C.)which PARK FEE Y_N
n all employer's under This permiL GAS-EA.SYSTEM-1 INC.4 OUTLETS
RECEIPT g
Policy If BUILDING DIVISION FEES
Company GAS Ek SYSTEM-OVER 4(PA) PLANCHECK FEE -
❑ Certified copy is hereby Tarnished.
❑ Cenificd copy is flW wird the city inspersion division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section wrest not be completed Blithe permit is foram hundred dollars(5100) SEWER-SANITARY-STORM EA.200IFT. ENERGY FEE
or less.)
I certify,that in the performance ofthe work for which This permit is issued,Ishut WATER ITEATER WNENT/ELECTR
not employ any person in any manner so as to become subject to The Workers' PAID
WATER SYSTI;MnREATING
Compensation laws of California. Date Dmc Rereiptp
z Applicant
z NEW RESIDENTIAL PLM. S FT.
NO'ncre subject
1.the WNT:IL after this Exemption, TOTAL:
g you should Q�
V3 bcchwithc mply thesuch r.po Compaaationpmviaiamofe elabm Code,you must
forthwith comply with such pravisiom or this pemdt shall be dermal residual. BUILDING FEE
pW,e Q CONSTRUCTION LENDING AGENCY SEISMIC FEF.
z I hereby affirm Nat Nereiaecovtruclion lendiagagency fortheper.crof TOTAL: ELECTRIC TLE
U O the work for which this Permit io issued(Ser.309],Civ.C.)
IY Lenders N:une
Lenders Address QTY. MECFIANICAL PERMIT PEE PLUMBING FEE
V 1 cenHy Nat T have read This application and sum Nu The above information is
>" LU correct.l agree to comply with all city and county ordinances and state laws mlating to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize mpresenmtivee of Nis city to enter upon the
U z above-mentioned property for inspection Purposes. ALTER OR ADD TO MUCH, CONSTRUCTION TAX
(We)agree m save,indemnify and keep here est he City of Cupertino against
liahiliries,judg ts,costsand expenx which mayinanywayaccomagalnstsaid City AIR HANDLING UNIT ITO IFMCITI)
in cons ue lithe grantin f AIR HANDLING UNIT(OVER I0,000 CFM)
as
'ignmu o AppliGl CannamOr Data EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATE DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt Is
Will the applicant or future building acceptor there or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Capetian Municipal Code,Chapter 9.12,and the HeoOh and Safety
Code,Section 25532(a)Y VENTILATION FAN(SINGLE RESID) a
11 Yes 13 No
BOILER-COMP(3HP OR 100,0ITTE BIT)
ISSUANCE DATE
WilltheoPPlicanumrlmare buildingoccupam uxeyuipmemordeviceswhiehemit• P ,Q,hazardous air conmmirems as defined by the Bay Am.Air Quality Management BOILER 110,000 BTU) - A i
DisvinT
❑Yes 13 No NEW RESIDENTIAL MECH. cri cu� ��
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 understand Thin SLL66SS
1993
if rhe building due,ma emremly have amount,that it is my nofonsibilRy m notify ere - C�I Y Ut GUr
occupant of the requirements which must be met prior to issuance of a Certificate of CI'I 1 a
Occupancy.
Ownermaumbnrizedageal Date ISSUEDBY:
OFFICE (�