25556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY O;"- S;
RTINO N ILUI C-ELF RICAI. PERMIT NO.
BUILDION APPLICATION/PERMIT PING PHOJ -MFICHANICAI. 25556 r 5 r 6
'}yk 3 � ""BUILDING PRUJEQGIDRN'TIFICQTION9;" r 3' ' L ^J �Vl FtNI
BUILDING ASANI'T'ARY NO. APPLICA'DONSUBMDTALDATLrIDUNIT# LOT# �OWNERSNAPHONE: CO AC'TOR'S NA r - LIC NO:
NIC CONTROL#.1111 CLIC NO: ADDRESS: ❑ W13
CONTACT: PHONE: v'n 1j t v1, '' s .a x t' "t -
HLECI`,RIC PERMIT k:I FEE' BUIEDING.PERMITlNFO
S�Ho I �0� ��j �/ B� ELECT PLUM MF. li
N / PERMIT ISSUANCE:
LICENSED CONAACI'OWS DECLARATION APPLIANCES-RESIDENTIAL ION DESCRIPTION
0Wz I hereby affirm dial am licensed underprovisionsof Chapler9(commencing with
4100 Section 9000)of Division 3 aflhe Busiressend Profusions Code,and my In. PANELS
Fyut full fore and effect." Lic.p— Or,axI—I}��—� C�•Srf�•I�� •
<<ZZ LicenseQ lass J.J � �s In 1 UP TO 200 AMPS �I
y6y Dom ZI11 Cor,tmc ` 201.11100 AMPS
ZOyz ARCHITECTS DECLARATION OVER IM AMPS SQ.FT.FLOOR AREA $/SQ.ff.
OZ-0 I understand my plans shell be used az public records.
r-t1`4 SIGNS ELECTRICAL /.•I�'
'9M Licensed Professional
C OWNER-exempt ear due ARATION SPECIAL CIRCUIT/MISC.
W O y V I hereby affirm That I em exempt from the Conhaat Co e:Any
yc Lew for the
W�+0 which following remaa(Sec1,O.IDosture .1.,,iandmprove,
profession Code:Anycity structure
TEMP.MEI'F.R OR POLE INST.
t E7�� which reyuiresa permit to cnnslrvct,aper,improve,demnlifi,ar rtpair,any sWnart
�:E prior to its issuance,also requires the applicant no such permi i to file a signed statement POWER DEVICES
ty—DOz m Nhe is licensed pursuant to be pmm
mvisians of the Conera License Law(Chapter
S%CLL 9(commencing with Section 7")of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC /�^ VALUATION
W_y Snhoheisex by therefrom the basis fonhealleged exemption.Any violation of (DIETS-SWITCHES-FIXTURES V
Z6
not
ne than by o hundred
collars $Permit auM1jecm the epplicannoncivil penalty of Lr4 lJ
not nano than five hundred dollars NEWREMDENTIALELECTR S .FT.
❑ I.mownernfilic oarty,ormyemployeeswiNwagesutheirsolccompcmation, _SQ.FT. 'INPE CONSTRUCTION
d3— will do the work,and the structure is not intended or offered for.[a(Sm.]044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
j property wholumidxorimproves theceagand who ones such workhireselforthroughhis
can employees,providedthat such improvements um not intended reoffered foraale.If, OCC.GROUP RES.UNITS
however,the building crimprovement is sold within one yeerofcompletion.Ne owner
builder will have the burden of Nat he did not build or improve for f T A
proving p puryoseo
• e rte{fp. i .;= g e . , y
Las owmeraftheproperty enexdusrvelycomeaetingwubllcenseJ cnntructo to QTY �a.° @gY PLUMING PI RMIT� ' 3 x FEE}4 A. FLOODZONE - APN
x"$''S! '
cam d the
project(Su.7044,Business and Professions Code:)The Contrecmr's PERMIT ISSUANCP.
Licca. Lewdocsnot apply mannwnerofproperty whobuildsorimproveslhereon,end
whovarmoo sforsuch pmts with acammctor(s)licensed pursuant to the Comrenor's
License Law. ALTER-DRAIN&VENT-WATER(EA) - y' FETE SUMMARY 41
❑ I am exempt wider Sec. ,B&P C far This reason BACK MOW PROTECT.DEVICE • 1 SID.F.;.
SANITARY YN
Owner Date DRAINS-FLOOR,ROOPARG,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Iherebyaf er lhmlhuve oceniFicate of,ansate msof-Insure,oracenificam of FIXTURES-PF.R'1'RAP �a RECEIPT#
.,kers'CompensmianlmuruncemecertifeA copy then.f(Sec.3g00,Lab CJw ch PARK FEE Y N
overs all employees under this permit. GAS FA.SYSTEM-1 INC.'I OUTLET RF.CF.IPTp
Policy# BUILDING DIVISION FEES
Mk
Company ` ,GAS-EA.SYSTEM-OVER 4(EA7I,m PLANCHECK FEE O O
❑ Certified copy is hereby famished.
❑ Certified copy is filed with Ole city inspection division, GRFASE/INDUST' 1 R GRADING IEE
CERTIFICATE OF EXEMPTION FROM WORKERS' �i&SETRAP SOILS 17CE
COMPENSATION INSURANCE IfL.
(This section neat not he cmnplemd if the permit is for one hundred Aollom($1 — SEWER-SANI'T'ARY- MIt200 vV ERGY FEE
or less.)
I certify that in the performance oflhe weak far which this passu is issued,I shell WATER HEATER W/VEMp31.EgFr-
oat employ any person in any manner so es as became subject to the Workers' PAID
Compensation Lawsof Califomia. Date WATER SYSTENUTREATING Date Receipt#
O 7r Applicanl
Z 0 NOTICE TO APPLICANT:ILafermaking this CeNfcam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
p] become subject the Workers Compensation provisions oflhe labor Code.you must
a ? forthwith comply with such provisions or this permit shall be deemed revoked. BUILpING EEE
W
5 z CONSTRUCTION LEN DING AGENCY SEISMIC PRE
1 hereby affirm that there is o construction lending agency for the perfornanre of T ELECTRIC FER
L) O to work I.,which this pennies Issued(Sec 3097.Ci,.C.)
W Leathers NomeR'jT
Lenders Address Q'IY 'd'+' 1MECFiANICAI''PEPLUMBING FEB
RMITj I "�'IEE `y.
U 1 ccrofy that I have read amts N s application sor Neson t the above inti Ix A' .h C 'T fir k'"' a a r
W correct.I agree to comply with city and county sndinances and stat,laws mining 1. PERMIT ISSUANCE MECHANICAL IEE 195
E-' k, building comuuctionand hereby outhariu repersenotives.fthiscity rocmer upon the CONSTRUCTION TAX
U 7 above-mentioned pmpeny,for inspection purposes. ALTER OR ADD TO MECII.
�-r (We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenla,costs and expenses which may in any wayiecrue against said City AIR I IANDLING UNIT(TO IQO00 CFM)
inn ee of gmnttn of Ni emit.
nIr//� AIR HANDLING UNIT(OVER I Do"CFM)
i mreof AppliconUContruclnr p[( ( Dale EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,1%X1 BITH Dam Receipt It
Wilt the applicant or fumm building occupant store ar handle baurdous material
as defined by the Capenino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)P VENTILATION PAN(SINGLE RFSID)
❑Yes ❑No
° BOILER-COMP DHP OR 100,"BTU) ISSUANCE DATE
Will the applicuntortLmre buildingoccupant us,aluipment ordevicessehichemit
xardous air comnminams os defrost by the Bay Arco Air Quality Management BOILER-COMP(OVER 1010,000 B'fU)
nP
❑Yea ❑Na NEW RESIDENTIALMECH. SQ.FT. P A,
ID
I have lead the haamdaus materials hosmocments under Chapter 6.95 of the
Culifnmia Health&Safety Code,Sections 25505,25533 and 25534.I understand iliac
if the building does nm curen0y have a hnanl,Nm it is my responsibility to notify the �rr(]. 1
occupant of the r pturentenls which must W met prior to issuance of a Certificate of
Occupancy. CivIaC 1I19U
Owner or authorixd agate Dam T'OT —2 TISSUED BY:
OFFICE