25156 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELErRI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL n C'1 G C
BUI1.1)INGPROJFIC'TIDFJNTIFICA'I'JON ' L J 1 J v
BUILDING ADDRESS: •� SANITARY NO. APPLICYGONSUUBBMITTALDATE
10-301 '"vV GG. UNIT# 1.01,#
OWNE N PHONE: %R'$NANO
CO ME: C L/aTS O v
��GG))aa V N/C CONIAOL#
RCHITECT/ENGINEI:R: LICNO: DR SS:,,:, ❑
70�15a DLL? OCK?UnJ/�1�' $ •-
OtTACT: PHONE: /5/d4r QTY.tr.- ;rt ELECTRICPERMIT "�� -g BUILDING PERMIT INFO
pPERMIT ISSUANCE. Ip BLDG ELECT PLUMB 1xi
❑ ❑ ❑
LICIINSEDCONT CTOR'S DECLARATION APPLIANCES-RESIDENTIALJOB DESCRIPTION
Iherchy affirm that l am licensed underpownsns of Chapter9 m
(comencingwiN
WOOF Sec tion 701 of Division 3 of the Business and Professions Cade.and my license is in PANELS �O�`],,.
�2Wfullforce end effect. UP T0200 AMPS KVtA �
4 License Class Lic.#
.<n. Date Commcmr 201-I W0 AMP
ZOrnZ ARCHITECTS DECLARATION OVER 1000 SQ.FT.FLOOR AREA S/SQ,FT.
OZ'—q lundentend my pluns,h.li heused ispublie rsemde,
q ryn�W SIGNS ELEC'IRICA
a C G Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�MOyF 1 hereby affirm that I am exempt from the Contra tot's License Low for the
� following reason.(Section]031.5,Business and Pmfessiuns Code:Any city or county TEMP.METER OR POLE INST.
C�'m J which requires a permit to consumer,alter,improve,demolish,or repair any structutt
CQ� portion its isauance..N.rtquirts the,office.,for such perrduo Haiti ned statement POWER DEVICES
!0 cs q O that he is licensed Folsom to the provisions of the Contractors License Taw(Chapter
9(c.mmencing with Srvim7")of Division 3 of the Business and Professions Code) SWIMMINGPOOL 'C'R III\ R VALUATION
WFF or that he is exempt Therefrom and the basis for the alleged exemption.Any violation of OUTLET3-SWITC FS- EA II\Vp
Z4 Seuion]031.3 by any opplicanr(ora permiuubjens me upplicannoecivil penalty of —
q not more than five hundred dollars(3500). NEW RESIDENTIA EL�tr(R�
c ❑ 1,asownerofthepnpNny,ormyemployceswithwagesasiheirsolecompensaiion, 'p( STORMS TYI'Ii CONSTRUCTION
y will do the work,and me,.ucture isnot inteadedoroffered for We(Sce.J044.Business
and Pore,,ims Code:The Comnctor's License Law does not apply t.an owner of
pmperry who builds.,improve,thereon,and who does such work himself or thmugh his
ownemployees,proviched that such improvements arenm imendedorofferedforsale.IL CC.GROUP RES.UNITS
howeve,he building.,of mosamrnt is sold wifluirme yenrofcompletiogtheo orer. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
s❑)I,asownerofthe property,amendusrvely. conwctingwimlcenud conwnont QTY,.Ptv"mPI.UMBINC PERMIT'yy�%#': �FEE'i' Fl.00D'LONE AI'N
,Lown the project(See.7044,Business and Professions Code)The Cman uses
License Lewdmsnotapplymanowner.fMopenywhobuii&orimpmvesmereon,and PERMIT ISSUANCE
who cormarvi for such projects with acontrueton,)Iicansed pursuant u the Contractor'sFEE SUMMARY
License law. ALTER-DRAIN&VEN'I--WATER(EA) .'r'
❑ 1 am exempt under Sea ,B&P C fm this reason BACKFLOW PROTECT.DEVICE OUT 'FEE'
Owner Dam _ SANITARY Y_N
DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL'1'AX YN
❑ Iherthy affirm thatlhaveacertificam n(consenuo self-irrsurt.mattnificnte of FlJCfURES-PER TRAP RECEIPT#
Wmkers'Cnmpensation lnsumnceoracenifiedc pymereof(Sec.3800,Lab C.)which PARK FEE Y N
covers Policy all emp7nyega pnrlef this�OL 95'x, 9-3 - GAS-EA.SYSTEM-I INC.40I1TLIiTS RECEIPT
II77 LL(( CC77 GGJJ 7 7�J BUILDING DIVISION FEES
Company • ate-
❑ CcniEed mpy is hueby fumished. GAS-EA.SYSTEM-OVER4(EA) PLANCI IECK FE F.
x�'Cmilied copy i,fled with the city inspersion division. GRIASF/1NDUSTRL WASTE INTERCEPTOR GRADING PEE
/ _ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE I
(Thie,eximmneed not be completrd ifthe permit is bounce hundred dollars($100) SEWER-SANITARY-STORM PA.20T ENERGYME
.r less.)
I certify that in the Perbommmce of the work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ am1,1roun in any marine,so as to become subject In the Workers' PAID
Q OCompensation Lawsof California. Date WATER SYS'PIN11TREATING Dm weipt#
Applicant a
Z NOTICE TO APPLICANT.If.after making this Certifies,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
!—I [1) hec.me subject the Workers Compensation provisions of Labor Code,you must
7 forthwith comply width such provisions mdo,permit shall lz deemed revoked, BUILDING FEE
(i CONSTRUCTION LENDING AGENCY SEISMIC FEE
zZ I hereby affirm Thai here is u construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ,C.) TOTAL: ELECTRIC PEE.
Lenders Nome :: T
0 [.enders Address QFY y , tuk MECIIANICAL PERMIT�z IEEE PLUMBING FEE
{U l terrify,that I have read tele application arta sore mat the above infommuon is 3 ° : v MECIIANICA ', /�
0. correct.I agree to comply with all city and county ordinances and seem laws retailing to PERMIT ISSUANCE
C,tj buildingcommuction,and hereby aumoou representatives ofthiscity toentcrupon the CONS C Tis
AX
U 7 above-mentioned popery for inspection purposes. ALTF.RORADDTOMECH.
G (We)agree to save,indemnify and keep humorless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way sector,against said City AIR HANDLING UNIT(TO 10,000 CEM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10,"CFM)
Signature,of Applicarl'Comtracmr Dom EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I0p0W BTU) Date Receipt as
Will the applicant or future building occupant store or handle hmerdous material HEATING UNI'1'IOVER IDO,IXIO BTU)
defined Nylon Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section❑Y a32(a)?)i�CN. VENTILATION PAN(SINGLE RP.SID) �a
Will lair c icaainarts m defined
by the Bay Area Arnt Quality
Management
BOILER-COMP(3HP OR 100,"BTU) ISSUANCE DATE
hazardous air contaminants az dcfned by the Bay Area Air Quality Management
Distrix? -0i COMP(OVER 100,000 BTU) p A i D
VVVVy
❑Yes No NEW RESIDENTIAL MECH, SQ.FT.
I have read the haz ous materials requirements under Chapter 6.95 of the JUN 151993
California I Icalth&Surety Cure,Sections 25505,25533 and 25534. 1 understand that
if the building does am curer have s tenant,mat it is my responsibility to notify the �r
I mf mite req me ¢ hie st Ix mu prior m issuance of a Cenifeate of Cp I Ur GV
authorize erg ISSUED BY: