25251APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINOHII7fINIrV,I:EQPIIIC -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MRCHANICAI,
s BUII.UING PRO,IRC'I,fUENTIIOCATIDN
PERMff NO.
C�iC
J G J
BUILDING ADDRESS:
SANITARY NO.
APPLICATION sualUTTAL DATE
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7.2 ".3 l\#+I- St--. UNIT# I.OT#
OWNERS NAME: PHONE.:
2' 3
AZ C J 7,3Z I
CONTRACTOR'S NA li: LIC NO:
NIC
❑
CONTROL#
HCH11hCUEJOINEER: \1V LIC NO:
ADDRESS:
'ONTACf: PHONE:
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Q ¢ps w iE4EGIRIG7PERMITw FEE
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'j;t4 i,?BUILDING
PERMIT INFO
BLDG ELECT PLUMB MECH
PER
PERMIT ISSUANCE
//I 7-,K — !NI
LICENSED CONTRACTOR'S DECLARATION
I hereby firm that l am licensedunder l'Cha t r9 c mmencin
Ya prd Profeso Code, y gwith
Seefiofull .sandef Division3of me Business and Professions Code. andm license is in
and
License laaerrem.
License Class Lic.N
Dam Contractor
APPLIANCES -RESIDENTIAL
PANELS
UP T0200AMPS fK
Yu00
400
Q Zurty
n?y
]ya
o
JOB DESCRIPTION
~QP/QQ Q tJ #�L��415
A
T
SQ. FT. FLOOR'ARI? Q. F.
� J II II T 'R
201-1000 AMPS
ARCHITECTS DECLARATION
1 understand my plans shill be used as public records.
OVER 1000 AMPS
SIGNS ELECTRICAL
WV
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Cay
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CC
3yo
Moo
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DATE L/ 2- / -2
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm @m I on exempt from the Coneracmr's License Law for the
following reason. (Sation ]031.5, Business and Professions Code: Any city or county
which requires a permit w construct, alter, improve, demolish, di repair arty swetube
In., its ismame. also requires, the applicant forsuch parrnitto file a signed statement
that he is licensed pursuant m the provisions of the Contractor's License Low (Chapter
9 Mrsmencing with Sectom7030 f Division 3 ofthe Business and Professions Cade
)o )
of
urthat ohe 131.5exempt nyappomand the Permittheaexempti to civiny l
%..bort Than byaundredicant olleas $50(d. tsubjeets the applicant toecivil penalty of
erist subjects
not momthanfivehundreddollars yemp.
❑ oyeeswithwegesastheirsWe compcnsiness
SPECIAL CIRCUIT/MISC./✓j�
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMWOPOOLELECTRIC
(�/ww/�w\ VALIIAT
Vf../I�J��
VVV coo
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECIR _SQ. FT.
STORIES
TYPE CONS'fItUC1'ION
yp
will domework.end the
ome woeroHhee, lancy,m hard so sl Business
notimmbense
oria
and Profasioas Crude: flue ContractorsLaw
ter s Law does nut apply lb an owner of
no, apply to an
pr ves he
eeywhobuildsorimproveschimpr and who acessuchworkhimselfedthrough his
road whr
OCC. GROUP
RES. UNITS
own employees, provided that sueaimpfavemrntsare foreale.lf,
sa,mendeaofoffercd
milder pthe buildie bandepmverocia,sal he did oneyear of completion. mpprd sof
builder will have the burden of pmvin8 that he did not build or improve for purpose of
t
- TOTAL:
QTpY1js q'r�P1.UMBING PERMIT 'L1 t "t:EE{
L ' 5t= 'rP
side.).
❑ I,asownerofthepmpeny,amesclusmelycontractingwithlicenxdedntr canto
construct the project (Sec. 70J4, Business and Professions Code:) TTe Chmmcmra
FLOOD ZONE
APN
I
License Lawn., but applym anhwnerofproperty, whobuilds or improves thc.,.d
whocraitmcts for such projmm with acontranor(s) licensed pufsuenO0 she Contracture
Lic mb law.
PERMIT ISSUANCE
ALTER (EA)
E
""FESUMMARY.
-
❑ I am exempt under Sec. B & P C for this mason
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR,ftOOF,AREA, COND.
OUTSIDE P "'
Owner Date —
WORKMAN COMPENSATION ARATION
❑ Ihcreby affirm thatl haveecenificam of eo mrosel nm, oracertificemof
Gisu
mker%Campensationlpsumnceoracenif.deny dimMf(S..38f0,Lm C.)wI ivh
Myers all employee'3 under this permit.
policy #
SANITARY V N
RI?CFIPT#
SCHOOLTAX YN
RECF.IPTp
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT #
GAS - EA. SYSTEM- INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTHM-OVER 4 (EA)
PLANCHHCK FEE
❑ Certified copy is hereby furnished.
❑ CeniBM wpy is fled with the city inspection division.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FP.E
SEWER - SANITARY - STORM EA. 209FT.
ENERGY FEE
(This section need not becompleted ifthe Permit is for one hundred dollars ($100)
or Ica.)
WATER HEATER W/VENTIELECTR
I certify, that in me performance of the work for which this permit is issued, Ishall
z
not employ any Poland in any mar as to become subject ro me Wmker,
Compensation Lawsof California. Date ran
Applicant
WATER SYSTEM/DtEATING
PAID
Dam Receipt If
O
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions ofthe Labor Code, you must
NEW RESIDENTIAL PIAS, SQ. Irl'.
TOTA
>
forthwith comely with such provisions or this permit.hall be deemed invoked.
BUILDING FEC
SEISMIC FEE
D
CONSTRUCTION LENDING AGENCY
z
O
FLenders
kUkl
6.
1 hereby affirm met more is a construction leading agency for me performance of
the work for which this person a issued (Sec 3097, Civ C.)
^�,
Namewltx
TOTAL:
-
ELECTRIC TEE
�
Lenders AddressQTY'
�
MECHANICAL PFRYv11T. t:a�Lf. ,.
a * 'k is x k "
PLUMBING FEE
1 candy that I have nom this application and stem that me above information is
correct. Iegrce a comply with WlMy ail county ordinances and state lows relating to
building construction, and hereby authonae repmxmatives ofmis city, to enter upon the
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
MECHANICAL FEE
CONSTRUCTION TAX
(We) agree to save, indemnify and keep handless the City of Cupertino against
Iiabilides,judgmmol,sasm and expenses whichnnay inany wayaccro, agairm said City
AIR HANDLING UNIT (TO 10,000CFM)
in consequence of a grantinpofmispermit.
AIR HANDLING UNIT (OVER 10,000 CFM)
CQ
Si;#YAU of ApplicantlContmconDam
EXHAUST HOOD C
PAID
HEATING UNIT (10100,000 HTU)
HAZARDOUS MATERIALS DISCLO E
Dam Receipt#
Will the applicant or Tamm building Mandolin store or andle hemNanus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 101),000 BTU)
L;
Code. Section 25532(u)]
11 Vex No
VENTILATION FAN (SINGLE RESTD)
Will mea licantor Nturebuildid
pp goecupantuxequipmemordeviceswhichemit
BOILGR - COMP (BIT OR IW,HIMI BTU)
ISSUANCE DATE
aw
PAID
aurdom air contaminants as defined by the Bay Area Air Quality Management
indm J
❑Yes �No
BOILER -COMP (OVER 100,000 BTU)
A'
1
JUL]�
NEW RESIDENTIAL MECH.—SQ. IT.
1c,
I hays mad the hazalloos materials oNuiremems send,, Chapter 6.95 of the
v`
993
alifomia I lulth & Safety Code, Sectiuns 25505, 25533 end 25534. I underhand mat
the building does not currently have a mmol, that it is my responsibility to notify the
ccupant of the requirements which must be met prim to issuance of a Certificate of
V I (fir VVrtn'll.
--
ccupancy.
BY:
wneforuuthoriacd agent - Date
TOTAL: ISSUED