25391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMRIING-MF.CfALE1 nuc PERMITNO.
BUILDING DIVISION ' . APPLICATION/PERMIT 25391
'BUILDING PROJECT I IIENTIFIC,A I ION
BUILDING ADDRESS: ��J y�Ifv'1/,- SANITARY NO. APPLICATION SUBMITTAL DATE
Gl I I '`WIJO / 1 U • UNITat LOT#
OW RS ZTE:_ PIRNE:�� CO R OR'S NAME: LIC NO:
J[O 55 NIC CONTROLp
• ARCHITECT/ENGINEER: LIC NO:
` A P. J 5
CONTACT: PHONE: A""fa (`iZtpU.3a:�eLrapw'x'D^IaTOr`te"D+x�° FEE, .+yxae❑
(�rH"U'IL^
DING PERMIT INFO
QTIC PERM
. BLDG
=
ELECT PL MUCH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCESRESIDENTIAL
I hereby affirm that l am licensed under rovismas of Chat 9(commencingith JOB DESCRIPTION
GCO'Z Ya P per w s r,
td00 Section 4000)of Division the Business end Professions Cade.and mylicenseis in PANELS /k�� /1��(/�n
tFr��U full force end e ^^ U wsT, T/t
FZ, License la_s �JV� fit. � '� i�- UP TO 200 AMPS
rn?vat Date Contractor 201-1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ZFO-4 ARCHITECTS DECLARATION OVER 1000 AMPS
OZ-0 1 understand my plans shall be used as public records.
ry�W SIGNS ELECTRICAL
ILicensed Professionalamm OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
yU 1 booby af8rn that I am exempt from the Contractor's Licmee Lew for the
real30 an fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ao fS O C which requires a Permit to construct,comer,improve,demolish,or repair any structure
} prior to its issuance,alsorequire,the applicant for such Permit o file a signed sNmment POWER DEVICES
<C) that he is licensed pursuant turns provisions of the Contractor's License Law(Chapter
Tq�, SWIMMING POOL ELECTRIC
0 9 that heisangwhh Seetlony00itthebasDivision 3of the Business and Professions Code) VALUATION
b. Ortho 7031. byanmpt applicanrcronat
f the permit subjects
thedexemptt to A civil Faulty
of OUTLETS-SWITCHES-FIXTURES
1.. ¢ Secrion'1031 5 by any applicant for a permit subjects the applicant[o a civil penalty of
a^g am one than five hundred dollar($500).
NEW RESIDENTIAL ELECTR SQ.PT. STORIES TYPE CONSTRUCTION
Wce ❑ othe work.aUhepmperty,ormyemployedconfwd!forslhei(sole7044,Bsiness
o, will Jathework,and the The cture Contractors License
La do es not applyde 70 g4,Business
and Professions Cade:The Contractor's License Lew urs not apply to an owner of
prapenywyvcs,psarimprovesthimpm ommosdoessuchwork himselrur hough his
employees provided Natsuchimpmvemenrsarono[Intendedorofhredforsele.If, OCC.GROUP RES.UNITS
however,the huildingorimprovement is sold within onsyear of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale). *. Ax4-n LS s tt ;x: +S;
❑ lasowneroftheproperty,emexelusivelycontactingwilhlieensedconuactosm Q i i,��PLUMBINGPERMUF ..PEfi}ya FLOODZONE APN
construct the project(Sec 7044,Business and Professions Code)The Contmemr'a -
Licenul.aw does not apply man ownerofpropeny whobuildsmimprovesthereon,end PERMIT ISSUANCE
who contracts for such p le<U with a contractors)licensed pursuant mine Contractors
ALTER-DRAIN&VENT-WATER(EA)
License Law. a�',: . _ . PEE SUMMARY °
❑ 1 am exempt under Sec. ,B&PC for Nis reason BACK FLOW PROTECT.DEVICE: T ID•PEES
N N
R CEIl M
Owner Date ➢RAINS-FLOOR,ROOF„ARE O
WORKMAN COMPENSATION DECLARATION i CH T Y N
• Warkers'Cot9mpp�neyrsGat im lnumnceoreerifiedcopy thereof(Secu3S00,Lab C.)which FIXTURES-PER TRAP . ,.� V' I, R•CFIPfp
Ferak R II RF.CEIPfN N
rs all eE/ +_dershis permit. GAS-G.SYSTEM-1 INC.4 O
Policy N N O — ILD NO DIVISION FEES
Company' s ! GAS-FA.SYSTLM-OVER4(EC) I FEFi-1-
❑ Certifieslcopyisherebyfumished, t
I;�4enified copy is riled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR — GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissection need out be completed if the Permit is forone hundred dollen($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or le..)
I certify that in the performances ofthe work for which this permit is issued,l shall LWATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the Workers' PAID
Compenssionfawsof California. Date - WATER SYSTEMTREATING Data Receirti
0 Z. Applicant
z 0 NOTICE TO APPLICANT:If.afrer making this CariPcmeof Exemption,you should NEW RESIDENTIAL TIME. SQ.FT. TOTAL:
p] becomesubjee[to the Worker's Compensation provisions of the Labor Cade,you must
foMwith comply with such provisions or this Permit shall ire deemed revoked. BUILDING FEE
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC ME the work for which this pmtt mIs issued(Sec 3097,Civ C.) a
w (r Lenders Name - x R g a p `K e a I d i x s y j {' �.
LL^^ Leaders Address QT•Y'"filt 4 MECHANICAL PERMIT;p ,� FRE ` ° PLUMBING ME
I ccmfy Nat I have read this application and side that the above information is
"a S i s°`
correct.I agree to comply with all city and county ordinances and state laws rending to PERMIT ISSUANCEa MECHANICAL.FEE
buildingconstruction,and hereby authorize representatives ofthis city[center upon the CONSTRUCr10N'TAX
(; above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
habilhles,judgments,costs and expenses which may in any way aeerueagainrsaid City AIR HANDLING UNIT(TO HOW CFM)
tie col the granting f his `intimi x ^
V L. AIR HANDLING UNIT(OVER BLOW CFM)
Signmure of Applicataac Date EXHAUST HOOD(W/DUCT) PAID
HE,➢OUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Date Receipt X
Will the the Caperfumreicipal Code,ng hapten at,,.or and tehavrdousmmedm HEATING UNIT(OVER 100,000 BTU) TOTAL: r.
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Ilealth and Safety
Code,Section 25532(a)'!
EI Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3I IP OR 100,000 BTU) ISSUANCE DATE
Will air contaminants
as building by the ueeeguipmir ualityc Management p
hazanlous air contaminu[s as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P pct
District?
11 Yes ❑Na NEW RESIDENTIAL,MF,CH. SQ.FT.
I have read the hazardous maerials requirements antler Chapter 6.95 of the NOV 22 1993
California Health&Safety Code,Sections 25505,25533 and 25534.T understand that
dial,building does not currently have a tenant,that i[is my responsibility to notify the CITY ur WN: II
occupied of the requirements which must be met prior m issuance of a Certificam of
Occupancy.
Owner or audmaized ager Date TOTAL: ISSUED BY: