25890APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC I RI AI.
APPLICATION/PERMIT PLUMBING - MECHBUANICAL
BUILDING DIVISION ILDING PIIOJE(, r IDEN'I'IFI(:ATION
PERMII'NO. r^ /}�( Q
25890
8 9 0
BUILDING ADDRESS.
SANITARY NO,
APPLICATION SUBMITTAL DA' BE
p `� J1
fJ
'`-' ` d eM^_JL�,&-.J (J UNIT# LOT#
2 �
OWNERS NAME: �1 PHONE:
J L, e- •y L�' h
CONTRACTOR'S NAME: LIC NO:
NIL
❑
CONTROL#
E RCI ITECIUE,NGI BER: LION
I a C. ' 'rS/
ADDRESS:
CoNTA.: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT FIX MECH
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that lam licensed under pmvisionsofChapmr9(cotmnencingwith
Section 700)of Division 3nf(he Business and Professions Cuda, and my license is in
Lull Lura ;lass effect.
I License Class Lic.#
APPLIANCES - RESIDENTIAL
)OB DESCR PTI OR
PANELS
UPT0200AMPS
i Data Convector
201 - 100 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be Land as public records.
OVER I"SQ.
P. FLOOR AREA
$/5Q. FT.
SIGNS .ECTRICAL
Licensed l'mfessiomOl
CIRCUI TSC.
I OWNER -BUILDER DECLARATION,CTAT.
1 hereby effinn that I am exempt from the Co nexamos License Law for the
TEMP. MEI N
ifollowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, aper, improve, demolish, or repair any structure
prion, its issuance, also requires the applicant for such permit to file a signed statement
POWER DEVIC
j Ohm he is licensed pursuanto, the provisions of the Commnof's License Law IChapter
9(commencing with Section A100) of Division 3 of rhe Business and Profeasmm Cade
or that he is exempt heafrom and the basis for the alleged exemption. Any violmiono
Section 7031.5 by any applicant for a permit subjects the applicant to a civil prmlty o
SWIMM OI.E IC
VALUATION
O -SWiT 1%TURFS
not marc than five hundred delta. ($50d.
❑ I,usowneroDhepropeny,ormyemployecswi@wagesus (heirsolecompensaioq
)FNTIA ' ECTR _S .FF.
STORIES
'ITPE CONSTRUCTION
will do the work,and thenrucmre N oin imeadedoroffnedfor sale (SecJ044,Businesc
and Professions Calc: The Convennev License Law does nm apply m on owner rf
pmpenywliobuildsorimpmves Hereon,undwhod ssuchworkhimxlforinmugh Ns
employees, proviJalthat such improvememsare notimendedoroffered forsale. If,
OCC. GROUP
RIS. UNITS
however. the building or improvement is sold within one yeurofcompletion, theowner-
builder will have the burden edproving (hut be did not build nr improve for purpose id
'TOTAL:
QTY.- _ PLUMBING PERMIT FEF.
sale.).
❑ I,ssownerof(hepopny,amexclusivelyconveaingwiNlice crnvemorsm
FLOODZONE
AI'N
convect the Podcn (Sec. 7094. Business end Portraitures Code:) The Cuntmetora
License Lawdoesnotupply to an ownerofprnpeny who buildsorimproves thereon, and
PERMIT ISSUANCE /
whociane", fnsuchpmjects wilt. comrumor(s) licensed purmet India Commcmre
License Law.
ALTF.N-BRAIN&VENT- )
WATER (HA)
FEE SUMMARY
❑ I un exempt under 5cc. , D & P C for this reason
BACK FLOW PROTECT. DEVICE
O '. .FS
SANITARY YN_
Owner Data
DRAINS - FLOOR,ROOP, AREA, COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Iherehy nifrtn(bmlh;rveacenificmc of consent ¢+self -insure, ornccnifica(e of
Workers Compcnsatirn lnxurancc orecenifiedcopy therwf(Sec.3#Op, Lab CJwhichsix
covers all employee's under this permit.
Policy #
SCIIOOLTAX YN
RHCHIPT#
FIXTURES - PER TRAP
PARK FEE Y_N
RECEIPT#
GAS - EA. SYSTEM- INC. 4 OUTLETS /�
BUILDING DIVISION FEES
Company
❑ Cenmulcrpyishembyfumished.
GAS - EA. SYSTEM-OVER4 (EA)
PLANCHECK FEE
❑ Cenifirscopy is fled with loceRy inspection division.
GRFASWNDUSTRL WASTE UUTIRCEPfOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRIASE9RAP
SOILS FEE
SEWER - SANITARY - ST ORM EA. 200FT.
ENERGY FEE
(Thin section need not he completed ifthe permit is for one hundred dollars ($100)
or lase.)
WATER I IIATM W/VENT/ELECfR
I Onlyflum inthe pcommu vsecothe work for which his .it is issued, I shall
not empty any person in any ..at so as to become subject to the Workers'
Comprnsmirnlswaof Celifomia. Data
Applicant
PAID
Dole Receipt p
WATER SYSTEM/fREATTNG
NOTICE TO APPLICANT': If. after making this Certificate of Exemption, you should
become suhjecno the Worker's Compensation provisions of the Labor Code, you mus(
NEW RESIDENTIAL PI.MB. SQ. FT.
'TOTAL:
BUILDING PER
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC ME
1 hereby affirm that (here is a construction lending agency for the performance of
TOT
ELECTRIC FEE
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Limit Address
QTY. M17CIIANICAL PERMIT PEE
PLUMBING FRE
I cenify that 1 have read Box ap,frta o r and state thin the above information is
PERMIT ISSUANCE.
MECHANICAL FEE
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of thiscity to enter upon the
above-mentioned n fur inspection a
props y pec p
AL'T'ER OR ADD TO MECH.
CONS'MUCTIONTAX
eposes.
( )agar to save, indemnify and keep hennless the City of Cupertino against
liabilii sPt ,nems,cosu end expenses which mayin my way eccmeagains(said City
AIR HANDLING UNIT (Tb 10,00(1
inco lucnce of th Leming of Ni nit.
HANDLING UNIT (OVER 10,000 CFM)
(;59tore of plicenUCnntst f D' c
XHAUS'1'HOOD (W/DUCIj
PAID
HLATING UNIT (TO 100,00 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt #
Will(heit,ticantor future building ce.prot store or handle hazardous material
as def ted by the Cupeninn Municipal Cale, Chapter 9.12, and the Health and Safety
HEATING UNIT(OVER I(#I,OW PTU)
TOTAL:
Code, Section 25532(a)7
❑Yes 0 N
VENTILATION PAN (SINGLE RESID)
Will the applicant r future building occupant use equipmen(nr devices which emit
BOILER - COMP UHP OR IOQ000 BTU)
ISSUANCE DATE
azardnus air cummtinsnu as dented by the Bay Acta Air Quality Management
3lstricfl
BOILER -COMP (OVER 100,000 BTU)
❑ Yes ❑ No
1 have read the hamrdous materials requirements under Chapter 6.95 of the
California I Ieahh & Safety Cade, S«tions 25505.25533 and 25534. 1 understand that
if the building does on' currently have a tenant, that it is my responsibility to notify the
�'
/p�
i e
NEW RESIDENTIAL MUCH. SQ. FT.
occupant of the requirements which must he met prior to Issuance of a Confine of
(7
q
TOTAL: l•
Occupancy.
(
PSSU D�A
BS
Owner oramhoriad,mm Date
OFFICE U/y`