25627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PINGPROcCTIDENTIFIC
BUILDING PROJECT IDENTIFICATION 25627
BUILDING ADDRESS: I SANITARY NO. APPLICATIONSUBMOTALDATE
r R UNIT# LOT#
OWNERS NA E:PHONCONTRACTOR'S NA LIC NO:
MY PHONE
r/ l� N e /�� NC CONTROL#
3
•
ARCHITECT/ENGINEER: LIC NO: W DRESS: a� J C
ar� M p n .ar°p gD r, ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 108 DESCRIPTION
y�z, Ifeerebyalfrm that lam licensed under,rovisicns of Chapters,(wmmencing with
00F Section Division 3of the Business and Professions Code,and my license is in ppNBlg � ^
Vt3 Lirerorceandeffece.
zz W License Class Lic.# _ UP TO 200 AMPS
F Q 4 Date Contractor 201-1000 AMPS
E^yZ� ARCHITECT'S DECLARATION OVER 1000 AMPg SQFT.FLOOR AR�FF�JJ�� � $/SQ.FT.
I
C z—O undemtund lh
my plans shall he used as public records. SIGNS ELECTRICAL
6 Licensed Professional
ua�5Iu� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ) ,1 I �'
30.1V- 1 hereby affirm that l am exempt from the Contractor's License Law for the
m following mason,(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR FOUR MST.
fJ o, which requires a permit to construct,alter,improve,demolish,or repair any momure ' 13
Nn prior m its issuance,also requires the applicant forsuch pennittufle asigned statement POWER DEVICES
fl
nATE
CO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a0.o�' 9(commencing with Section 7")of Division 3ofdm Business end Profeasiom Code) SWIMMINGPOOLELEMIC VALUATION
W..m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Q Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
t morethanfrvfthepreddollamye pl NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
n❑ ochel.aswrk,and
or ofered forsalei(sole 044,Basins,
43� will dmthnwon;and 1, The murure actmt is License Low
at apply town Business
and Professions Code:'Ihe Contmcmrx License Lew does not apply w un owner of
property whohuildsea improves thereon,and whodoes such work himseiforthmugh his OCC.GROUP RES.UNITS
wnemployees,providedNet suchimprovcmen[s aenminteralmorafferedforsale.If,
however,the building orimprovement is sold withinoneyearofcompledon,the owner.
builder will have the burden ofproving that he did not build or improve for purpose of Tom 7 At e
sale.).
❑ I,mownerofthepropeny,amexclusivelycontractingwiNlicensedconvactorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.704,1,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Law does nor appl y to an owner of property who bui ld s or improves thereon,and
whocontmets for such projects witha coarseness)licensed pursuant tothe Contractor's
License Law. ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt under Sec ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dam RECEIPT#
co DRAINS-FLOOR,ROOF,AREA.CONI.
WORKMANCOMPEcamofcNDECLARA'GON SCHOOL TAX Y N
❑ en'Co affirmthmlhrance or aexurmof copytherof(Sec.38 or Lab C.))which
RECEIPT#
Workers'Com FIXTURES-PER TRAP
pensatian Insurance ore certified copy thereof(Sec.3800,Leb CJ which PARK FEE Y N
rs all employee's under this permit RECEIPT#
GAS INC.40IITLETS
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certifedcopy is Bled with the ciryinspadon division. GREASFIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATIONINSURANCE
(This sm[ionnced rotbe completed if Ne permit is force¢hundreddollas($100) SEWER-SANITARY-STORM EA.20(1 ENERGY FEE
or less.)
I certify shin in the pertormance ofthe weak for which this permit is issued,l shall WATER HEATER W/VENT/ELELTR
not employ any person in any manner so a to become subject to the Workers' PAID
Compensation Lawsmf Califanim. Dam WATER SYSTEM/TREATING Date Receipt#
p z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FL TOTAL:
(/) become subject to the Worker's Compensation provisions of the Labor Code,you must BUILDING FEE
�i forthwithprevisions comply with such pvisions or this Permit shall be deemed revoked.
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7. z I hereby affirm that there is a construction lending agency for the performance of . 72
U O the weak for which this permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC HE �#
OE Lender's Nene PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEE
LTI1 certify Nat I have reed this application and state that the above information is MECHANICAL FEE
corect.Iagree to comply with all city and county ordinances and state laws relating m PERMIT ISSUANCE
building construction,and hereby amhorizempmsentatives ofthiscity enumeration the CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
limbil itieajudgments,casts and expenses which may in any way secrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,00 CFM)
Signature of AWlicams7omuxctor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 100,000 BTU) Date Receipt#
Will the the Cupertino
on future Municipal
Code,C unt smrc or hanand the
Health andntrusions Safety
HEATING UNIT(OVER 100,000 BTU)
al
as defined by the Cupertino Municipal Cade,Chapter 9.12,end the Heilth and Safety
Code,Sec[loa 25532(a)7
11 Yee 11 No VENTILATION FAN(SINGLE RESID)
CE DATE
Will the aPPlican[orfuwrebuildingocapuntuseequipmento(devices whichemit BOILER-COMP(3HP OR 100,000 BTU)
• hoommus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER❑ CI100,000 BTU) ®�� 1 ��#�Y,�
District? Yes No NEW RESIDENTIAL MECH. SQ.FT. d
I have read the hazadpas materials requirements under Chapter 6.95 of the .C(�' UI' CUPth I INU
California Health&Safety Code,Sections 25505,M533 and 25534.I understand that
if Ile building does not currently have a mason,that it is my responsibility to notify the
occupant of the require arose be m prix t issuance of a Certificate of
Occupancy,
Owner or nothorizedfiVI.,F v ( Date TOTAL: ISSUED BY:
OFFICE