25635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUnar PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT .PLUM ROJECTeDENTIFIC 25635
BUIIAIN(i PROJECT IDENTIFICATION
BUILDING ADDRESS ,p SANITARY NO. APPLICAIONSUBMITTALDATL•
/oto/ N n/a UNIT LOT
ERS AME: PHONE: CONTRACTOR'S NAME: LIC NO:
f
'2 VZ—(.3/3 N/C CONTROL#
•ARCHITECDENGINBE : LIC NO: ADDRESS: ❑
CONTACT: PHONL:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE fib' El 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB
I hemb ffirm Nm l am licenudandcr sicnsofarimr9 mmumencinwiN TOB DESCRIPfION
❑t8Z Ya Provi P 8
W O fall
orce it ofoiviaion3of the Bulinus and Professions Cede,and my human is in ppNE1,5 (�'
F full tome d<Httt. UP TO 200 AMPS (� (�{[
FZ,on Licenu Class Lic.N
m 6 L Dam Contractor. 201-1000 AMPS
z oo ARCHITECTS DECLARATION OVER IWOAMPS SQ.Ff.FLOOR AREA E/SQ.PI'.
OZ
1 mdmunit my plans shell be used as public records.
SIGNS ELECTRICAL ` r r\. n r 11 II�
qyad , Licensed!Professional
Q
OWNER-BUILDERmDECLARATION SPECIAL CIRCUIT/MISC.
ippiS5,,OaF 1 hereby affirm that 1 m exempt from the Gonion Ce License Law for the
uY3 LL rQn following rennin.(Section]03 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
W2O7
which mtsioa aPermit onconnruct,alcor,improve,demolish,me saigany structure
��Y� primrmitsissuance,alsortquirtaN<applicantforsuchpemuuofikasignedsutmem POWER DEVICES __ /0 /
W K Map That he is IicrnsM pursuant m Ne provisions of the ConmctoCs Lianx Isw(CTrapmr
d oT 9(commencing with Section]000)of DiviaionJo(the Buaineu and Profusion Cade) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exept mtherefmmaudthe basis for dmiolt,,m exemption.Any violmionof OUTLET'S-SWITCHES-FIXTURES
ZG Section 71111.5 by any applicant for a permun
it subjects thimplict toacivil pcnehy of
^� nm then five hundred do][.($500).
� � I,mownerofthepraper monympl.,eas withwageaasdamemlecampenuuon. NEWRESIDE14TIALELECIR —SQ.FT. STORIES TYPECONSTRUCI'ION
a will do the work,artd the atr«ture isnot intended proffered forsole(Sec.]OJ4,Business
and Pndessions Cade:The Ciar acma's License Law does not apply to an owner of
property whobuildsorimpmves Nemon,and whores such work himxlforthmughhis OCC.GROUP RES.UNITS
own empl oyees,prov ided that such improvemen tsam not immmdcd or of fered for sale.If.
however,the buildingorimprovment is sold within one yearo(completion,theowner- �w
TOTAL:
builder will have the buen of,rovkg that he did not build or improve for post os,of
rd
we.).
❑ Lnownerofthe property,wnexclmiv<ly<ontmcung with licensed conuecmnto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
octane,the project(Sec.7044,Business and Professions Code:)The Connector. PERMIT ISSUANCE
License Low does not apply a un owner of property who builds or improves thereon,and
who contmcu mrsuch projects with amnracmrho licensed pursuant mthe Conmstors
License Law. ALTER-DRAW&VENT-WATER(y) FEE SUMMARY
❑ 1 am caem ,B&P C for Nis reason O I m
' - BACK FLOW PROTECT.DEVICE SANITARY YN
nw„e ��-� D RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
Wn (M AN COMPENSATIONDECLARATION SCHOOLTAX Y N
❑ Ins'Co afflrmthat lhave.
unce m ificemofco,,tharwf(sert insum,o,Lab C)which
RECF.IPfN
Wmkeri Com FI%TURES-PER TRAP
pertsetionlvomna orecenifcd copy Nereo((S«.3g00,lab C)which PARK F[E YN
covin els employee's under his permit. GAS-y.SYSTEM-1 INC.4 OUTLETS RF.CEIPO N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTI?M-OVER 4(y) PLANCHF,CK FEE
❑ Certified copy is hereby famished.
❑ Ccrtifed copy ie filed with the ciry inpation division. GREASETNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS TEE
COMPENSATION INSURANCE
(ITissection need nm be completed lithe permitis form hundreddollma(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perform.«of the work for which this permit is ismed,l shall WATER HEATER W/VENT/ELGCTR
not employ any person in any marrou an u to become subject to the Workers PAID
Compensation) wsof California. Date WATER SYSTEM/IREATMG Dom Receipt#
O z Applicant
z0 NOTICE TO APPLICANT:If,after making this Cenifsca ,of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL:
V) baome suhject to the Worker's Compensation provisions of the Labor Code,you most
�-' forthwith comply with such provisions or this pemut shall be denied revoked. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEF.
z I hereby affirm that there is a construction lending agency for the pi,domwee of
V O the work for which this Permit is issued(Sec.309],Civ.C.) TOTAL: ELECTRIC FEE #
I" Lender's Name PLUMBING FET.
Lender's Address QTY. MECHANICAL PERMIT FEE
V 1 unify that I have read this application and mute that the above information is MECHANICAL FEE
cored. I agree to comply with all city and county ardmances and sum laws misting m PERMIT ISSUANCE
building construction.end hereby a uNoriumprommaiva ofthiscity menterupon the CONSTRUCTION TAX
(J above-mentionmd propcny for inspecrion purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino aguint
liabitilm,judgmenu,costs and expenses which may to my way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in comemence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.00)CFM)
Signature of Applicant/Commcwr Date EXHAUST HOOD(W/DUC , PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Iffl."BTU) Dam Receipt#
Will the applicant or future building occupant mote or handle haurdons material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Ciipcnino Municipal Code.Chapter 9.12,and Ne Health and Safety
Coda Section25532(e)7
0 Y CI No NTVEILATION FAN(SINGLE RMID)
ISSUANCE DATE
Will theopplicanmrfuwrebuilding«cupantuuegoipmem ordevices whichemit BOILCR-COMP(JHP OR IW,IXNI BTU) /l^
hamrdous air contaminants u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) ! ^/'p l'
• Distnctl YYY
❑Yes EI No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous mammals re ore mens under Chapter 6.95 of the �C7141993
California I Iealth&Safety Cade,Sections 25505,25533 and 25534.I ura mtand that
if the building does not currently have a tenant.that it is my responsibility to notify the
p teflggTe uiremen¢ u which must be met prim N issuance of a Cenificam of a /alMv tar �gUrtn
«cu rasa �\yr//JJ(is/��- V I 1
Owns thoflzeda ant am TOTAL: ISSUED
OF I