25008 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BmITS1NT-F.cECTRICAL PF:RMITNO. 25008
� C'O O p O
APPLICATION/PERMIT PLUMBING MECHANICAL.
HULLOING DIVISION GJ
BUILDING PROJECT III EN'J'IF'ICATION
BUILDING ADDRESS, /s� //�}�� SANITARY NO, APPLICATIONSUBMLTTALDATE
10953 �i/�i/I SDN I✓ 1 UNIT as LOTM
OWNERSN ME: /,
PH ON CONTItACTON'S NAME: LIC NO: N!C 'CONTROL#
NCIII'IECIyENGINEER: LIC NO: A D PSS:
CAUR°/ "e
CONTACT: PHONE:
/�`.I QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
rip!►R Pl9810-9oyyB6ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEM'IAL JOB DESCRII'I'ION
pyz Ihereby offom that lam licensed order 1mvilimal.fax,orro hournmmncing with
Fw00 Section 70(1Bo1'Division 3 afthe Business and Professions Code,and my license is in PANELS
UF furceandef
Fi- �..�,� t
Da
ZVW License Class Lie UP102MAMPS
why part Contractor 9 201-IOOOAMPS
Fy ARCHITECTS DECLARATION SQ.PT.FLOOR AREA MQ.FT.
p
Z rn�' OVER 100o AMPS
OZ I undcrshnd my plain shall harmed us Public records,
r-E�q{ SIGNS ELECIRIGAI.
'] Licensed Profesainnel
CCQ OWNER-BUILDER from
mDECLARATION SPECIAL CIRCUIT/MISC. T
OyF I hereby nfftnn that 1 um exempt from @e Contractor's License Lew for the )
31'-m following meson.ISwtion 7031.5,Business and Professions Ode:Any city or county TEMP.METER OR POLF.INST. D
l:vo oo.1 Minch rcgoima u pcnot h omeamOt,aher,improve,demolish,or repair any structure /
CECWT� prionsimissuance,alsorequi¢s the uDPlicam forsuch pemtiva Fileusigned atahmwv POWER DEVICES A E
W C G 0 that he is licensed pursuant m the provisions of the Contractors License Law(Chapter
0.0.pfl! 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC - VALUATION
yl'^y or that he is exempt therefrom and the basis for thealleged exemption.Any violation of
FZa Section 9031.5 by any applicant for a permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
Kyy not more than five hundred dollars($500).
Fo ❑ I,mownemfNcproPerty,ormyemployeeswithwaga astheirsolecompenxotioa, NEW RE9IDPMIAL ELECfA _SQ.PI'. STORIES TYPE.CONSTRUCTION
W3°.-° will do thework,and the structure is not imendedoroffered Porale(Sec.]Odq Business
and Professions Code:The Contractors License Low does not apply to on owner of
property whobuiIdsoimproves thereon,and whodues such work him elforthrough his
own employees,provided thatsachimprovcmentsurcnot imendedoroffertvl foraale.If, I OCC.GROUP RES.UNITS
however,the building orimprovermat is sold within one year ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did tens build or improve for purpose of
sale.). Ql'Y. PLUMBING PERMIT FEE 11,00D ZONE APN
❑ Loa ownernett(prop7ny,atnexclusi ad Prtrectivgwithlic:)The Contractors
icemor the project(Sec.]044,Business and Professions Cade)The Comcon.ans
Licensetrawdonnmapply toanoh.ourpropeny Hwho emard ds pumrimto do, ontracors PERMIT ISSUANCE
who
two La .forsuch projects withucomracmKa)liunud pursuantmthe Contractors
License Lew. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em exempt under Sec. ,B A P C for this reason .BACK FLOW PROTECT.DEVICE SANITARY Y—N
—
WORKMAN
IDI:FEE.
Owner pate RECEIPTM
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,CONED. SCHOOLTAX Y N
1 hereby offirm that I have a mciftcah of somata to self-intim,ar a certificate of RECEIPT p
FIXTURES-PER TRAP
mcoversr%eampmvtion lnsumnce ora<enifal copy Ncrwf(Sw.JB00,LobCJ which PARK FEE Y N
BOB cy pllemPlo�'9 yrs en^is pe4 'L //D//,• GAS-EA.SYSTEM-1 INC.4 OUTLETS RDIVISI N
N 7 (L BUILDING DIVISION FEES
Company S'IYI GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ Cenified copy is hcrcby furnished.
Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
('Phis section need not be completed ifthe permit is foronelonfird dollars SHXB SEWER-SANITARY-STORM EA.200FT. ENERGY EEE
or less.)
I certify that in the performerom of Ne worn for whichthis permit is issued,l shall ' WATER HEATER W/VFNT/ELEM 5
no employ any person in any manner so ns h became.object to the Workers 7. ZF
PAID
Compensation Lawsof California. Date WATER SYSTEM/TREATING Date RettiptN
Q z Applicant
z Q NOTICE TO APPLICANT:If.after melon#this Certificate of Exemption,you should NEW RESI DPNTTAL PLMB. SQ.FT. TOTAL:
F' VJ become andaimuo Be,Workers Cion mamiun provisions of the Lehr Code,you must
a. ; forthwith comply wiN such provision or this pertain shell he dwmcd invoked. BUILDING IT
CONSTRUCTION LENDING AGENCY SEISMIC FEE
rte- z 1 hereby affirm that there is a construction lending agency forms performance of TOTAL: ELECTRIC FEE
L) O the work for which this permit is issued(Sec.3(19],Civ.CJ
loader's Na
O me
U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING EEE
LLI I certify that 1 have read this application and soh that the.bove inf ntmation is MECHANICAL FEE
correct.legreeto comply with all city wdcnunty ordinances and snob laws rclatingm PERMIT ISSUANCE
h building constriction.and hereby authannamprcaenwtiva oflhis city to enter upon the CON$TRDLTIDN TAX
U above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify end keep harmless 0e City of Cit whiaa against
liabiliticajudgmem,costa and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CEM)
in comsegacnm of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Sigratale of ApplicontlConhucwr Data EXHAUST IIOOD(WIDUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt N
Will the applicant or future building occupant store or handle lsmardous material HEATING UNIT(OVER 100.00)BTU) TOTAL:
n defined by the Clpenimo Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(e)?
❑Yes 13 No VE THI ATION FAN(SINGLE RESID)
Will thea applicant or fumrcbuildin area BOILER-COMP(3HPOR 100,000 BTU) ISSUANCE DATE
pp g pant usecquipmentoNeviceawhichemit
intuitions our contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? EI RESIDENTIALPAID
Yes ❑No NERESIDENTIALMECH. SQ.FT.
I have read the hamNous mandals requimrmur.under Chapter 6.95 of the
if
ulIngdosSafetyCode,aveate25505,25531and25534. 1umdemandthat UL 201993
California the building does not contrarily C llc haveamoans,Notit is wJ25534ibilitymnotifyfor
occupam of the regniremems which must rd inn poor to issuance of a Cenificme of
Occupancy. C"1 b
L I1
Owner or authorized agent Dote TOTAL: ISSUED BY: 1�� [/
OFFICF