25397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION - •-- z PERMIT NO. 25397
BUILDING DIVISION APPLICATION/PERMIT PLGPROJE PROJECT IDE
BUILDING PR(3JECT IDN:N'TII4CA'I'ION
BUILDING ADDRESS: /'�� SANITARY NO. APPLICATION SUBMTIT'AL DATE
of R7 WG.C/ - UNIT# LOT#
O ERS NAME: PHONE.: CONTN TON'S NAME: LIC NO: NIC CONTROLp
i
• AKCHITEC/ENGINEER: LIC NO: ADDRESS nA ❑
SS Lc.2tA m GCS
CONTACT: PHONE:
FEE BUILDING PERMIT INFO
't6e&41' EEEGfRI PEIRrMIT ;,
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Q=z I hereby affirm that Ism licensedunder provisionaof ChVter9(commencing with
u1OW0 Sectlon 1000).(Division 3 of the Business and Professions Code.and my license is in PANES -
FFU full force and eff Q 1/
Qz License Clas�I Lic.# UP TO 200 AMPS '` �Y
,6 0. Dam�-+ ?%C, r71 �(6.p¢.��/ 201.1000 AMPS
l"vOi Z '- - ARCHITECTS DECLA TION SQ.FT.FLOOR AREA S/SQ.FT.
z0 Z=O 1 understand my plans shall be,used as public retards. OVER IOW AMPS
SIGNS ELECTRICAL
�KKC Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
np'OyF I hereby if,.that 1 am cxcmpr from Ne Contractors Lt..Law forme
:1 following mown.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
tE:O0 which r quire a permit to constmcL alma,improve,dmlalish,or repaG any suunoe
prim m its iawamm,also rqubes dim.,Iic.t for such permit m file a signed su¢ment POWER DEVICES
G 0K that he is licensed pursuwno the provision of the COntrea4ra License law(Chapter
a^Oo 4� 9(commencing with Section0000)of Division 3 of Ne Businessand Professions Cade) SWIMMING POOL ELECTRIC VALUATION
p _y other he is exempt Nomfrom and the basis for the alleged exemption.Any violation of -
> Section 7031.5 hymynpplicantfor.permilaubjecb them,licammitavil Penalty of OUTLETS-SWITCHES-Fl%TURPS
Gnot more than love hundred dollars T$500). YJs�
yy � ❑ I,ssownaofNepropeny,omyemplayaawithwagexsstheirwlemmpensetion, NEW RESIDRNT4ILELECTR _SQ,PI'. STORIES TYPECONS'TRUCTION
iwill dothewmk,andlimmuctura is notinuidedoroffered I..ale(Sec.9044,Business
and Professions Cade:The Conuecrors License Lew does not apply w an owna of
property who builds or improver thereon,and who does such work himuelfor through his C.GROUP RES.UNITS
owncmployms.pmvided Natsuchimpmvemenuamnotin¢ndWd offeredfor We.If,
however.the building orimprovement is sold within one yearafcompletion,theowner- TOTAL: �^I f�
builder will have the burden of proving Net he did not build o improve for purpose of '� ! I�`v I r \ '—
sale.). QTY,���;. PLUMBING PERMIT FEE FLOO'["!"Eu
ZO E �3PN
❑ I,es the Mjrtheprogeny ,Buss urs and onnactingwithlicensedconnanor¢to k,. �xs , 3 !"E ''� F
icensesonowdet the project(Sec.TBn4, lmtofp end PwIlicywho bon C,i.p The he n.wr - M a J J r ,OKI
License Law dceanot epplYm nnownerofpropmy who build orimprovethereon,end PERMIT ISSUANCE
whownt=BforwchpmjauwiNamnmcwds)licmn pursuanttothe Conowtoes ALMS VENT-WATER(FA)
License Law. yypEATE
❑ I am excmpt undcr Sm. ,0&P C for Nis reason BACK FLOW PROTECT.DEVICE
SANITARY Y_N
Owns DateRAT DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'#
WORKMAN COMPENSATION SCHOOL TAX Y N
1 hereby affum thin 1 have a certificate edconsent a ul(Smure,m.cmifimuch RECEIPTp
FIXTURES-PER TRAP
eos'Cnmpenulion Insurance oracmified copy Nerm((Sa.3600,Ub CJ which PARK FEE Y N_
covers all F ye'seer this perm it GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FEES
Policy#j 1�
Company S p—s- � GAS-EA.SYSTEM-OVER 4(EA) PLANCHPKFEE
�JCertified copy IS hereby fmmshed.
�J Cenifed cnpYir fledwiNNe city inpecuon division. GREASPJINDUSTRLWASTEINTERCEPfOR GRADING FEE
I` ,CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This section madrom becampleted lithe permit is Just hundred dollars($10J) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or leu.)
I certify that in the imfomwlce of Ne weak fo which Nis permit is issued,Ishall WATER HEATER W/VENT/ELELTR
not employ any pawn in soy mermer so u to become subject to the Workers PAID
Compcnsanonlawsaf California. Due WATER SYSIEMITREATING Dau Receipt
z Applicant
O O NOTICETO APPLICANT:If,after mein Nie Cenificate of Exem TOTAL:
g ption,you should NEW RESIDENTIAL PLMB. gQ,FT.
tz+ � become subject to the Worker's Compensation provisions of the Labor Code,you must
•" fordwithcomply with such provisions or this penin shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCYr SEISMIC FEE
ffi
I hereby arm Nat there is a construction lending agency for the perfeamence of ELECTRIC FEE
V O On, er
work for which this pmit is issued(Sm.300],Civ.C.) TOTAL: aV
Lenders Name
(.ks PLUMBING FEE
�+ Unders Address QTY.-' MECHANICAL PERMIT FEE -.�
Q U 1 cenify that 1 have read Nis applicafol cad sure slut the above infonneu n o ¢.h t i•'a,
correct. l agree to comply with all city and county ordinances andsuu law.relatimgI. PERMIT ISSUANCE MECHANICAL FEE
building construction,mdbereby authorise lepoesenuGvesofmiscity toentaupm the CONSTRUCTION TAX
V 7 above-mentioned progeny for inspection purposes. ALTEII OR ADD TO MECH.
(We)agree to save,indermilly and kap hammers the City of Cupertino against
liabilities,judgmenb,costs and expenses which may in any way accme against said City AIR HANDLING UNIT(TO 10,0130 CFM)
'n cnnscquence of thegun Hof is permit
AIR HANDLING UNIT(OVER 10,000 CFM)
ignawre of Apphcan ontmcto Dau EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Dote Receipt#
Will the applicant or future building occupam store or handle haaadaus material HEATING UNIT(OVER 1 W,IXIO BTU) TOTAL: -S
ss defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(o)P VCNTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will Neapplicamarfutumbuildingmeupantuwequipmentordevims whichemit BOILER-COMP(3HP OR IW,"BTU)
hanudous air commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
•
District?
EI Yes 13 No NEW RESIDENTIAL MECH. SQ.FT. DEC ' 91993
1 have read the hawdms materials realm under Chapter 6.95 of the a V
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that cil y
if the building door not currently have a mount,that it is my rosponsibility to notify the ser Vhf tKl�
occupant of Ih<requiremcma which nun be met prior w issvwce of a Claificeu of
IXcupwcy.
Owner ar wthorised agent Dew TOTAL: ISSUED BY: