25295 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPESION RICAL
APPLICATION/PERMIT PING PROG-MHCHATIFIC
BUILDING DIVISION BUILDING PRUJF.CT IDENT'IFICA'TION
PLRM 3 "°
25295
BUIL )INGADDRESX _
UNIT# LOTH
SANTT I'ARY NO.APPLICATTIIIONSUBMIT'ALDATI
�_� ^1
OWNS AMI:: WC PHONE:
`
C NTRACTOR'S NAME: LIC NO:
NIC
❑
CONTROhp
ARCH, ECfENGINBE LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
B .LE PLUhJB M
7f-PERMIT ISSUANCE
LICENSED
I hereby atl=l CONTRACTOR
under pmvPrionsof Chapter9 (co mmencing with
rtethut I am lithe
APPLIANCES. RESID
JOB DESCRIPTION
of Bu
5[CIIon 9UIX1)of Division 3of the Business and Professions Cade, and my license is in
full force and eff«e.
License Class Lic. #
PANE
DPT A
Baa_
■�D /
ftl>
Date Contractor
201-
ARCHITECTS DECLARATION
1 understand my plans shall o used az public recmds.
R 1 AMPS
PwRFA S/SQ._FT.
{,OQR
ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP. METER OR POLE FIST,
following reason. (Smuon 7031.5. Business and Profesaims Code: Any city or county
which fia,mres a permit to construct, slier, improve, demolish. or .,if any s.cmre
prior to its issuance.alw requires the applicant for..uch Permit o file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisiorla of Rise Commem's License Law (Chapter
9(commmcing with Section 7000)of Division 3 of the Business and Preasimvs Code)
n did he,, eacmpnherefmm and Ne basis for the alleged exemption. Any AnItaimid'
Section 7031.5 by any applicant for a permit subjmu the applicarn ... ivil penaltyof
SWIMMING POOL ELECTRIC
VALUATIOry��y�/s
OUTLETS - SWITCHES - FIXTURES
no mart than rofve hundred dollars ($500).
❑ operty,mmyemployedorofwagesasthei(sole compensation,
`
NEW RESIDENTIAL ELECTR _SQ. FT.
STORIES
TYPE CONSTRUCTIOD
othewrk, and
will do thcwons Cad the iso offered
Code: The Contmcturs i enspr
he Clio se, Licenses note(Sm.in an owner
Law does not apply m rd owner of
and Prinerty
whionx
nd who
pmpery whobuildsorimproves ch whodoesmuch work himselfonhmugh his
Own employees, p rsuch imparr:md
not e. If,
forshe
OCC GROUP
RFS. UNITS
building or improvementeariff curoHemd
ovemenpmvementhin
however, the building or improvement is sold within one year ofcompletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
of
QTY. PLUMBING PERMIT FEE
ale.).
❑ Lacowner of the property,Cm exdusivelycmvacting with licensed mntranonm
FLOOD ZONE
APN
construct the Nojen (See. 9044, Bmincas and Profession, Code:) The Cmao m .,
License Law does not apply to an owner ofpropeny who builds or improves themon,and
PERMIT ISSUANCE
who contractsfor such projects with a contractor(s) licensed pursuant to the Convectors
Llcemctaw.
ALTER-DRAINffiVENT-WATER HiA) /
FEE SUMMARY
❑ 1 um exempt under Sec. , B ffi P C for this reawn
BACK FLOW PROTECT. DEVICE
Of/TSIDE FS
Owner Dom
DRAINS- FLOOR, ROOF, AREA, COND,
SANITARY YN_
RECEIPT'#
WORKMAN COMPENSATION DECLARATION
[IIhcmby affirm Natlhaveeccnificme of<onummselLia$.,ore fern cateof
Workers'Compenmtian msumned or a certified copy thereof(Sec. 3800, Lab CJ wM1ich
revere of l employee's under this permit
Policy N
SCHOOL TAX YN
RECEIPT#
IF FlXTURES - PER TRAP '�•
pg RK FEE Y N_
RECEIIT N
GAS - EA. SYSTEM-] INC. 6 OUTLETS
BUILDING DI VISION FELS
Company
❑ Cenifled copy is hereby famished.
GAS - EA. SYSTEMERn ' ) ii ll r �^^
LA FEE
❑ CmiOed copy is filed with the city inspection division.
GREASF/INDUSTRL WASTE RCEPTOR 1
G N- ^.
CERT1121CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP n
FEE
(This section need not hecompleted if Ne permit is for one hundred dollar($100)
or less.)
SEWER SANITARY-dTDRM IPL
'IPL
I certify that in the perfonnanu of Ne work fm which this permit is issued, l shall
nm employ my person in any manner so as to become subject to the Worsen'pglp
Compenmtionl.awsof CNlifomia. Dam
Applicant
WATER HEATER W/VE /ELECIR
WATER SYSTEMiTHEATING
Dam Rmeiptp
NOTICE TO APPLICANT, If. CfW making this Cedificsa of Exemption, you should
become subject to the Workers Compensation provisions of the Labs Cade, you must
forthwith comply with such Provisions or this permit shall ba dimmed revoked.
NEW RESIDENTIAL PLMB. SQ. FT
DOTAL
BUILDING FEE T�
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for the performance of
SEISMIC FEE
ELECTRIC PEE
the work for which Nis permit is issued (See. 3097, Civ. C.)
Lender's Name
Lenders Address
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
I certify Nat 1 have read Nis application and state Net the above information is
PERMIT ISSUANCE
MECHANICAL FEE r
nect. l agree to comply with all city and county ordinances nod state laws rtlaingm
building construction. and hereby audimee mmeas mauvaof this city to enter upon the
CONSTRUCTION TAX
move-memimed property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments. costs and expenses which may in my wayseemeagainsticad City
ce of.h granting Nis permit.
ALTER Oft ADD TO MECH.
AIR HANDLING UNIT(TO HL" CFM)
AIR HANDLING UNIT (OVER I1.000 CPM)
��
Slgnat Apeman meammr Dam
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO IO(LXO BTU)
t
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocmpxnt store or handle hazardous material
Dam Receipt #
TOTAL:
as defined by the Cuperino Municipal Cork. Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)y
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE REMO)
❑Yes El No
I
Will or future building equip menmuality
BOILER- COMP OR 100,000 BTU)
p� XIVI$DATE
forapplicant
inumb by tummy
h mous nit <onmminants us defined by the Bay Arca Air Quality Management
Manage ant
DixWcf7
BOILER -COMP (OVER I(0,000 BTU)
Ryy p/� /�Y
P A I Y
❑Yes 0 N
NEW RESIDENTIAL MECH.-SQ. FT.
I have mad the hazardous Sections 5505,25533 under Chat wi 6.95 all theJY�iYy(
ifthebuildingdoesnot aman5505,s it is yrutpond 30. 1undnrstmd that
if the wilding dh&Safety Coly have
ments lyhaveatenant,thatitismymuanceofa enotify the
Occupant o[Ne requirements which mon he mm prior m issuance o(u Certificate of
�y� �,i L1i uu(-CI 1 NU
CIIi OF CUPEHTI
Occupancy.
BY:�
Owner or authovN agent Dae
ISSUED
n