25604 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' B ILUI r• ,L. TRI A PERMIT NO.
BUII,DING DIVISION APPLICATION/PERMITPr.wn,e'r,•- 25604
BUILDING PROJECT IIIEN'1'IPICAI'ION
BUILDING ADDRESS: SANITARY NO. APPIJCATIONSUBMITTALDAIB
UNIT# LOT# l�- 1,3
OWNERS NAME: ` PHONE: CONT�1'pR'$ly4 LIC NO:
.J COW
`� N/C CONTROL#
ARCIIfH"M-NGINEER: ICN . ADDRESS: ❑
92 r
CONTACT: PHONE: BUILDING PERMITINFO
' QTY. ELECTRICPERMIT FEB
BLDG FLOCT PE UMP M[CH
PERMIT ISSUANCE
LICENSED CONfRACfOR'S DECLARATION pPpLIANCES-RESIDENTIAL
r ell
I hemb ffiw that l am licensed under p ( gwi JOB DESCRIPTION
nezzPOO ya prd profession,
commencin with
�v100C Sectiorce an effect,Division the Business and Profeasiom Code,and mylicense ISIS PANELS \/Vf`r�fl�M'O�TI'l�/✓
�tLC Lull force and cream.
FZtu License Class Contractor—
UP TO200AMPS ` �—
tiQd Date Commmor 201-OVER
1I AMPS
� SQ.FT.FLOOR AREA S/SQ.FT.
�mZ ARCHITECTS DECLARATION OVER IOW AMPS
ZO Z 1 understand my plans shall he used as public rtcomds.
Y SIGNS ELECTRICAL
C Lic.n.W Profcssi.nul
OWNER-BUILDER DECLARATION17-1 SPECIAL CIRCUIT/MISC.
OyU 1 hereby affirm Nat 1 am exempt from the Commenco,License Low for the
3 n.N following..on.(Section]031.5,Business and Professions Code:Any city or county TGMP.METER OR POLE INST.
which requiresapermit to construct.alter,improve,demolish,.,repair any structure
KW},; prior to its issuance,also requim the applicant for such permit an file a signed statement POWER DEVICES
W'<O O ,hut he is licensed f ursuanno the provisions m the Conouns
mea License Law(Chapter
'E:Q 9 commenting with Scomm 7")of Division 3 of the Business and Pmfearions Code) WIMMING POOL C VALUATIp1Iar
y_y or that hei osempuherefromand thebssis fortheollegMesemption.Any violation of wO� C/a���
LZ< Section]031.5 by any applicant for a pewit subjects the applicant m a civil penalty of OUTLETS-SWITCHES-FI S r`J
X40 notion Eve hundred dollars(53110). NEW RESIDENTIAL ELECfR .FT.
p�6Cp crofthepeopeny,ormyemployees withwagesasthcirsolecompensation, STORIES TYPE CONSTRUCTION
y I I Pmf se im,l and c:no Cmume of imm�dcd orofw does not apply
1 an,Bus
I d Imy who
hiobu Code:The Com,omnr's License .ca docs not apply m on owner is
mn enywyees,pdso,impmvestliinip anmentsumavciiend iofferer through his OCC.GROUP RES.UNITS
employees,p Ing or improvement
himprovemmnsarene oudcompleered for sale. r.
boweveq the building arde.mvemem is sold.within one year df completion,the owner. T
builder will have the burden.f proving that he did not build or improve for purple of LAC
male.).
❑ Lusnwner ofthepropeny,amcadmively conveningwithlicemed conwnom. QTY. PLUMBING PERMIT FET: .FLOOD ZONE APN
construct the project(Sao 704,1,Business and Professions Cade:)The C.mmcmra PERMITISSUANCE
License Law does not apply to an ownerofpmpeny,who builds or impmves thereon,and
astmemtrects formaliprojectswithaconwmnud IimnsedpursuemmuLa Cantmemes ALTER-DRAIN&VENT-WATER
License law. MEA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICEOUISIDEFE
SANITARY Y N
Owner De¢ RECEIPT#
pRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONofoome DECLARATION SCHOOL TAX Y N
❑ Ihcmby,emstthat lhave om.cemeof conscnu"Zf'-Snsure,0,Labificmech pIXTURES-PER TRAP RECEII'Tq
Wnrkc.1 Compensationlc,,huaeo,omrtilicd wpY thereof(Sec.3Bo0,LabCJ which PARK FEE Y N
covers all employee's undenhis pewit. GAS-EA.SYS'TEM-I INC. OUTLETS DIVISION
R #
Policy q BUILDING DIVISION P SES
Company GAS-EA.SYSTEMOVER I M1 NCH C
KFF
❑ CenifiedcopyisherebyfumishM.
❑ CerifiW copy is filed wit the city impectio,division. GREASFJINDUSTRL WAS INTERCEPTOR GRADIN6 AN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SAIL
COMPENSATION INSURANCE
(This nemi.n need not be complded i(the pewit is 6r on<hundred dollar(Stan) SEWER-SANITARY-ST RM EA.
or leas.)
I certify that in the performance ofthe work for which this pewit is issued,I shall WATER HEATER W/VF ----- ,_ _
not employ any person in any manner sn as to become subject to the Workers PAID
Compensation Laws.f Califomis. Date WATER SYSTEMfFREATING Date Receipt#
p 7-+ Applicant
z 0 NOTICE I'O APPLICANT:IL after makingthis Certificate of Esentlame,you should NEW RESIDENTIAL PLMR. SQ,FT. TOTAL:
become mbjmt to the Workers Compenmtion previsions of the Labor Code.you must 411
IY forthwith comply with such provisions or Ida pewit shill be deemed revoked. BUILDING FEE /a
W ..
t1 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 hereby affirm that these is a construction lending agency for the perfommntt of TO ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Co.C.)
Landers Nome
LL, PLUMBING FEE
Ic
OF U I<nd Add.. QTY. MECHANICAL FEE
certify that 1 have rt it all application and iou and Stam that an above information is MECHANICAL FEE
>" 4 morn, logrtt to comply with all city and county ordinances and ante laws relating t. PERMIT ISSUANCE.
U 'z hadding comtroctiot,and hereby authorize Tepmaematives ofthiscity roamer upon the CONSTRUCIONTAX
ulmve-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We).,me m save,indemnify Lord keep hunnless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT G70 10,00)CFM)
ine.mequence of the granting of this pewit N/
AIR HANDLING UNIT(OVER IO,OW CFM)
Signnm of ApplicanBC.nwnm Date EXHAUST HOOD(W/DUCD PAID to
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO U100,0100 BTID Date Receipt#
Will the applicant or buildingCoad,, pmtmom m hanand the Horrdousmrterid HEATMG UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
❑Yes 13 N. VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will mheopplicanmrfuwre buildingeecupat useequipmentordevices whichemit BOILER-COMP(3HP OR Must"BTU)
• harenl.u.s t Ir conmminumb as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,0(m BTU)❑ El1�L�55
Yes Na NEW RESIDENTIAL.MECH. SQ.FT.
ID
I have sad the hazardous materials requirements under Chapter 6.95 of the WILLCalifornia Health&Safety Code,Sections 25505,25533 and 25534.1 understand Nm
if the building does not cumntly have a tenant,that it is my responsibility to notify the Y
occupant of the requirements which must be mer prim to issuance of a Certificate of TV
Occupancy.
Owners authorized agent Date TOTAL: ISSUED BY:
OFFICE