25843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DII.DINC fiLEC7RICA. PERMTfNO. C O �l �]
BUILDING DIVISION APPLICATION/PERMIT r''""""""-""OCinN""'' 5843
BUILDING PROJECT IDEN'I IFICA'1'IfIN
BUILDING
AADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT# / /S A7OWNERS NAME: PHONE: CON"rRACTOR'S NAME: LIC NO: NIC CONTROL#
aV' r V A Zf -771
•ARCATE_ CI INLER:� LIC NO: ADDRESS:
CONTACT:r_„_A_/J ElPHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MGCH
PERMIT ISSUANCE 0 ❑ E�-_ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
LTa'Z Iherehy offtm that l sen licensed underprovisions of Chap¢r9(commencing with
W 0 CSection 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
tky-s-��VE fullfnce and effect. ��7'K Ile-4
/
FZW License Class Lic.# UPT0200AMPS
ti 5 N
Data Connector 201-1000 AMPS SQ.FT.FLOOR AREA MQ.FT.
ZOO�T5 ARCHITECTS DECLARATION OVER TWO AMPS
0 Z t,❑ 1 understand my plans shall he used ns public records.
rm5w Licensed ProfessionalSIGNS ELECTRICAL p F.
g� 11 r�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. -, I 'I '7 II pal
kO y U I hereby affirm Nat 1 am exempt Dom the Contactors License Law for the t D J 0 tl
3 ec following reason(SaGon 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which room.a permit to co arms.alter,improv`,demolish,no.pair any atremure , P
CWQ� primto its issuance,also requites the applicant for such permit to file a signed statement POWER DEVICES
py C p that he is licensed pursuant to the Provisions of Ne Contrecwfa License law(Chapter
dip 9(commencingwish Smion7000)ofDivislon3oftheBusiness'andProfessions Code) SWIMMING POOLFLECRIIC DATELU ON I
or that he is exempt therefrom and the Basis for anthe alleged exam�ion.Anyviolmono( OIITLEfs-SWITCHPLZ
S-FIXNRPS _tete!
F_Z Q Scotion 7031.5 by y applicant for a permit subjects the starlit i m a civil penalty of
not more then five hundred dollars(5500). NEW RESIDENTIAL ELECIR _ Q. .
C � ❑ I,ssownerofthepropeny.ormyemployaswithwegasutheinolecompenstomm. SFTSTORIES TYPE.CONSTRUCTION
,s,3. will dothewmk,and the structumboot intended moffered forsale(Sec.7044,Business
and Professions Code:The Convector a License Law does not apply to an owner of
pmpenywhobuildsorimpmvestheman,and whodcessuch wods himselforthmugh his OCC GROUP RES.UNITS
employas,provided that such improm
veentsarenot intendedoroffered for W e.If,
however,the buildingor improvement is sold within one yeaofcompletion,theawne, TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
A1.as ownerofthe property,amexclusivelyeommoling with licensed contractors to QTY. PLUMBING PERMIT FEE PLOOD'lONE APN
construct the project(Sec.7004,Business and Professions CWa:)The Contractors
License Lawdoes not applym an ownerofpmpmy who builds mimprovts thereon.and PERMIT ISSUANCE
who contracts forsuch Projects with a contrecrorts)licensed pursuant to the Contractors
License Law. ALTER-DRAIN& FA
VENT ( ) FEE SUMMARY
❑ Ism exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SID FS
SANITARY Y N
Ower, a p /Y RECF.IPf#
• covers WOR AN COMPENSATION DECLARATION DRAINS-Fl.00R,ROOF,ARLA,CONO. SCHOOL TAX Y N
❑ l hereby affirm that l have a certificate ofcon.nt m self-insure,m a certificate of RECEIPT#
FIXTURES-PER TRAP
Workers'Cnmpansatianlnsunncermit. nifed copy thermf(Sec.38flo,lab C.)which PARK FFE Y N
all employees under Nis permit. RECEIPT#
GAS-EA.SYSTEM.I INC.4 OUTLETS
PoI cy# BUILDING DIVISION FEES
❑ComCetffied copy is hereby famished. GAS-FA.SYSTEM-OVER 4(FA) PLANCHECK PEE
❑ Certified copy is filed with the city inspection division. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
(This section sad not Be completed ifthe Permit is for one hundred dollars($UXd SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or less.) C
I terrify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECR
not employ any person in any marmer so as to became subject to the Workers PAID
Compeasatiou Lawsof Califomia. Dole WATER SYSTEM?RFATING Data Receipt#
z Applicant
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
became subject to the Workers Compensation Provisions of the Labor Cade,you must
� > forthwith comply with such Provisions or this Permit shall he deemed revoked. BUILDING HE
1Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ I hereby affirm that thea is a construction lending agent for the perfomence of
O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: j,a1-.,y ELECTRIC ME
Lenders Name
OF finders Address QTY. MECI[AN[CAI.PER MIT FEE PLUMBING FEE
U 1 certify that I have read this application and sate that the above information is MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and state laws reluting to PERMIT ISSUANCE
building concoction,and hereby audomw representativesofthis city to enter upon the CONSTRUCTION TAX
U Z above-mentioned progeny for inspection patients. ALTER OR ADD TO MECH,
(We)agree to save,indemnify and keep hermits¢the City of Cupertino against
liabilities,judgments,costs andexpcoos which may in anyway memo against said City AIR HANDLING UNIT IT010,OW CFM)
consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signomreof Applicant/Commenr Dae EXHAUSTHOOD(W/DUCn PAID (1.�s"r r3 7299
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dote Receipt If
WINE,applicant or future building occupatn itoa or handle hazardous mmerial ��
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I esti B'rU) TOTAL:
Code,Section 25532(.)?
11 Yes XNo VENTILATION FAN(SINGLE RESIDE
E DATEJA
KU
Will theapplicamorfuture building occupamm
use equipmcordeviceewhich emit BOILER-COMP(JFIPOR 1100.000 OTU) p'n W y
• havNous air contaminants as defined by the Bay Arco Air Quality Management BOILER-COMP(OVER UX),000 BTU)
District?
❑Yes „K4. NEW RESIDENTIAL MECH, SQ,IT. DEC 15 1993
1 have read the ham don maarials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that [,f1 I HVU
if the building does not cumtnly have a tenant.that it is my responsibility to notify the CI,Iti V'
covpant of the requirements which must be t prior io n,1[ce of a Certifcme of
Occupancyr- S
WMI D l t
Owner or vuthmined agent Data TOTAL: ISSUE
OFFICE-__