25150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R 1 DI .- LLC' R1 AL PERMIT NO. 1�
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGROJECTEDENTIFIC n rA 1 C O
BUILDING PROJECT IDENTIFICATION LJ J
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
UNIT# LOT#
OWNERSN E: PHONE: CO(�`'.'RACfOR' NAME: LIC NO: N/C CONTROL
It
ITE¢{ENGINEER: LIC NO: ADDRESS: C97
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{- gbh
CONTACT: PHONE: Qom, ELECTRIC PERMIT FEE
N BUILDING PERMIT INFO
�QS Caw /._) PERMIT ISSUANCE DG PLUhW M�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _ C/I��JS`-
Ihereb fftm thetlem licensed ander p (Commencingwi JOB DESCRIPTION
❑CZ ya ead Professions
mr9 th
1+100 Sermon 9000)of Division3of be Rosiness and ProfeaeiorLs Coda and an,license is in PANELS O
full fame and effect. �+
ZR
License Class Lic.N Z_-� UP TO 200 AMPS O
way Dme Cornractar p 201-1000 AMPS
ARCHITECTS DECLARATION OVER ILOO AMPS SQ.FL FLOOR AREA WSQ.Ff.
O Z'-'D 1 understand my plans shall be used as public merits.
SIGNS ELECTRICAL `�e
aU Licensed Professional lobr+
y a OWNER-BUILDER frmEC ContraON SPECIAL Cf IS
E 1 hereby affirm that I am exempt from the Cocoons Co License Law for the
W 3 a y¢ following reaenn.(Section construct,
Business and Professions Code:Any city structure TEMP.ME R S
2 n Oy J which requires n permit N construct,eheq improve,demolish,or repair any evuctor t POWER D ES
2y� that hor oslicensed .also purmusmtoth Nevisionsocant for theuchpemmitroLicele a se La (Cha wt
that he is licensed with
Section 7000)
the provisions of the Contractors License Lew(Chapter
d c0. 9(commencing with geaion 0000)of Division 3of the Business and Professions Code) SWI IN LELBC //EVALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of sixLETS-S CHM-FIXTURES ^ x/�1� fqgq �J
4 Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty o vL/V
O not mom than five hundred dnllnrs(8500). NEW RESIDENTIAL ELECTR -SQ.FT. STORIES TYPE CONSTRUCTION
p ❑ I,usowneraHheprop dy,ormyemployeeswiNwagesestheirwlecompensation,
y will do the work,and the structure isnntatended oroffered foliate(See. Business
and Professions Cole:The Convector's License Law does not apply to an owner of
property who buildsorimprovestemaxo,and whodoes suchwork himselforthrough his
own employees,provided thatiuch improvementsarc not Intendedowffeciformle.If, I OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden minoring that he did not build or improve for purpose of 0 L
sale.).
❑ [,as ownerofthe property,amexclusively contracting with licensed convactorsm QTY. PLUMBING PERMIT PEE ,FLOOD ZONE APN
construct the project(Sec.7(a44,Business and Professions Code)The Contractors PERMIT ISSUANCE
License Law does notapply tounownerixTroperty whobuildsorimpmves miammmand
who contracts for such projects with a cantracushid licensed pureuam to the Contractor's
License Law. LTF.R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under gee. ,B&P C far thio rcawn BACKFLOW PROTECT,DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX N
` Ihereby affirm certificate that l have a cercate of consent to Self-insure,or a certificate of IXTURFS PER TRAPS
RAP RECEIPT
rkas'Compensatian lnamance ora cerifced copythawf(Scc.3800,Lab C.)which PARK FEE N
cums all employee's under this permit LAI
GAS-EA.SYSTEM-1 INC.4 OUTLET #
Policy# BUILDMO D141SION FEES
Company GAS-E A.SYSTEM OVER 4(EA) PLANCHECKFE lb
❑ Certified copy Is hereby modified.
❑ Certified copy is filed with dm city inspcmion division GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS M d ...wwo
COMPENSATION INSURANCE
(This section need not be completed Him permit is forome hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. I ENERG FEE
Mr i s)
I certify that in the psrformanceofthe work for which Nis permit is issued,I shall WATER HEATER W/VENT/ELEM
not employ any person in any manner so as to become subject to the Workers PAID
Compensation Lawson Califomm. Date WATER SYSTEMGREATING Data c.i in Its
O z+ Applicant
NOTICE TO APPLICANT:If,after nursing this Certificate Rpti P ryqmId SID PLMB. SQ.FT. TOTAL:
accurate subject to the Workers Compensation provisions of th CaboY C&day yodmmist ' _
�i forthwith comply with such Provisions or this permit shall be ed ievoked. /I BUILDING FEE '
W Q CONSTis
RUCTION LENDING AGENC y�fi �\v/�1 IJ u j� tl IIR SEISMIC FBB
U z I hereby affirm that there is a construction lending agency for the performance of
the work for which this t is issued(Sec.3097,Civ.C.) 6' ELECTRIC FEE L
O Ani
Lenders Name
OU Lenders Address _ MECHANIC-At PERMITFEE PLUMBI
Lki I certify that I have read this application it state that the above information is MECHANICAL FEE
correct I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and herebyaullardmrepacomati,miff Nis city to emorupon the CONSTRUCf1QNTAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree no save,indemnify and keep hamdeas the City of Cupertino against
IiabiliY a,judgmenq costs and expenses which may in ywey ecerueageinstsaid City AIR HANDLING UNIT(TO 14000 CFM)
yuence of the gm f Ni. it.
AIR HANDLING UNIT(OVER 10,00X1 CFM)
SMAture of ApplicanUCmann Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) �� Dace Receipt#
Will t c it,scant or future building eccupant stme m heMle harcum aus materiel HEATING UNIT(OVER 104000 BTU) A
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
CWe,Section 25532(a)4 VENTILATION FAN(SINGLE RESID)
❑Yes ' EI No
ISSUANCE DATE
Will NeepplicanmrPowre buildingoecupwtuse equipmenwrdeviceswhichemit BOILER-COMP(3HP OR 100,000 BTU)
ardoua air contantinunts as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
vlc4
❑Yes ❑No - NEW RESIDENTIAL MECH. SQ.FT. Fy A P D
1 have read the hamrdous meterials requirements under Chapter 6.95 of the ANCalifornia Health&Safety Code,Sections 25505,25533 and 25534.I understand that ���
if the building does not currently have a tenant,that it is my responsibility notify the 1115
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Ownertamthmixodagem Date TO ISSUED BY: �`�